LECTURES 

ON 

DISEASES OF THE NERVOUS SYSTEM, 
ESPECIALLY IN WOMEN. 



LECTURES 



DISEASES OF THE NERVOUS SYSTEM, 



ESPECIALLY IN WOMEN. 



S.' WEIR MITCHELL, M.D., 

MEMBER OF THE NATIONAL ACADEMY OF SCIENCES J 

PHYSICIAN TO THE ORTHOPEDIC HOSPITAL, AND INFIRMARY FOR DISEASES OF THE 

NERVOUS SYSTEM ; 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; 

MEMBER OF THE NEW YORK ACADEMY OF MEDICINE J 

ASSOCIATE FELLOW OF THE AMERICAN ACAHEMY OF ARTS AND SCIENCES OF BOSTON 

HONORARY MEMBER OF THE STATE MEDICAL SOCIETIES OF NEW YORK, 

NEW JERSEY, AND MARYLAND; 

HONORARY CORRESPONDING MEMBER OF THE BRITISH MEDICAL ASSOCIATION ; 

HONORARY FELLOW OF THE LONDON MEDICAL SOCIETY J 

HONORARY MEMBER OF THE ST. ANDREW'S MEDICAL GRADUATES' ASSOCIATION J 

FOREIGN ASSOCIATE OF THE ROYAL MEDICAL SOCIETY OF NORWAY ; 

AUTHOR OF A TREATISE ON INJURIES OF NERVES, ETC. ETC. 



v~ 



WITH FIVE PLATES 



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PHILADELPHIA: 
HENRY C. LEA'S SON & CO 

1881. 



J*' 




Entered according to Act of Congress, in the year 1881, by 

HENRY C. LEA'S SON & CO., 

in the Office of the Librarian of Congress. All rights reserved. 






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COLLINS, PRINTER. 



DEDICATED TO 



J. HUGHLINGS-JACKSON, M.D., F.R.S., 



WITH WARM PERSONAL REGARD, 



IN GRATEFUL ACKNOWLEDGMENT 



HIS SERVICES TO 



THE SCIENCE OF MEDICINE. 



1* 



PREFACE. 



The lectures which compose this volume deal 
chiefly with some of the rarer maladies, or forms 
of maladies, of women. Many of them are original 
studies of well-known diseases, and others deal with 
subjects which have been hitherto slighted in medical 
literature or which are almost unknown to it. 

I desire to express my thanks for very valuable 
aid to my colleague Dr. "Whartox Sinkler, to 
Professor Horatio C. Wood, to Dr. Louis Starr, 
and especially to Dr. Morris J. Lewis. 



CONTENTS. 



LECTURE I. 

THE PARALYSES OF HYSTERIA. 

PAGE 

Paraplegia — Hemiplegia — Bilateral hemiplegia — Electric re- 
actions in hysterical palsies — Treatment . . . .13 

LECTURE II. 

HYSTERICAL MOTOR ATAXIA — HYSTERICAL PARESIS. 

Briquet's hysterical ataxia — New forms of hysterical ataxia — 
Forms of paresis ........ 34 

LECTUKE III. 

MIMICRY OF DISEASE. 

Causes of mimicry — The hysterical state — General nervousness 
— General failure of health — Psychic peculiarities — Natural 
mental and moral conditions favoring mimicry of disease — 
Imitative vomiting — Imitative palsy — Mimicry of pain — 
Imitative epilepsy — Imitative meningitis — Epidemic of 
rhythmic chorea . . . . . . . .50 

LECTURE IY. 

MIMICRY OF DISEASE. 

Hysteria in childhood — Simulated vomiting — Simulation of 
hip-joint disease — Autobiographical confessions . .75 



CONTENTS, 



LECTURE V. 

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN WOMEN. 

PAGE 

Rotatory spasms — Functional spasms — Strychnic spasms — 
Spasms on change of position — Local spasms simulating 
tumors — In the pectoral muscles — In the walls of the 
abdomen — In the gastrocnemius — Hysterical athetosis . 89 

LECTURE VI. 

TREMOR — CHRONIC SPASMS. 

Hysterical tremor — Nervous tremor with organic disease of 
the spine — Alcoholic tremor in nervous women — Chronic 
spasm with simulation of local injury of ulnar nerve — Chronic 
spasm of leg — Contracture of leg muscles — Chronic spasmo- 
dic ptosis . ... . . . . . .106 

LECTURE VII. 

CHOREA OF CHILDHOOD. 

The relations of the chorea of childhood — To season — To 
climate — To locality — To race — Forms of chorea . .127 

LECTURE VIII. 

HABIT CHOREA. 

Definition — Cases of habit chorea — Relation to chorea of 
childhood — Treatment . . . . . . .146 



CONTENTS. XI 

LECTURE IX. 

DISORDERS OF SLKEP IN .NERVOUS OR HYSTERICAL PERSONS. 

PAGE 

Sensory shocks — Emotional shocks — Irregular motor dis- 
charges — Nocturnal functional hemiplegia — Respiratory- 
failures in sleep . . . . . . . .153 

LECTURE X. 

VASO-MOTOR AND RESPIRATORY DISORDERS IN THE NERVOUS 
OR HYSTERICAL. 

Pulse in hysteria — Agitation of heart followed by apparent 
death — Eccentricities of pulse in the hysterical — Palpitation 
of heart with Hushing of face — Palpitation of heart with 
pallor of face — Surface ischemia — Vaso-motor paralysis 
in the limbs or the face — Extreme vaso-motor paralysis 
of the whole vascular system of the abdominal cavity — 
Respiratory peculiarities of hysteria . . . . 1 74 

LECTURE XL 

HYSTERICAL APHONIA. 

Paralysis of laryngeal muscles — Failure of coordination in the 
various organs which combine to produce speech . .191 

LECTURE XII. 

GASTRO-INTESTLNAL DISORDERS OF HYSTERIA. 

Comparative rarity of hystero-epilepsies in America — Diffi- 
culty of feeding hysterical women — Troubles as to masti- 
cation — Forms of dysphagia — Hysterical anorexia — Hys- 
terical vomiting — Hysterical fasting — Defecation in hys- 
teria 201 



Xll CONTENTS. 



LECTURE XIII. 

THE TREATMENT OF OBSTINATE CASES OF NERVOUS EXHAUS- 
TION AND HYSTERIA BY SECLUSION, REST, MASSAGE, ELEC- 
TRICITY, AND FULL FEEDING. 

PAGE 

Character of cases needing this treatment — Seclusion — 
Nurses — Uterine disease — Ovarian disorders — Seclusion — 
Rest — Massage — Electricity — Mode of feeding . .217 



For Description of Plates, with. Remarks, see 
pages 127 to 145. 





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/ Dotted line the temvperatuTe curve . 
Z Ulcbck. Tine InfantiZe jjalsy cases. 



DISEASES 

OF THE 

NERTOTJS SYSTEM, 

ESPECIALLY IN WOMEN. 



LECTURE I. 

THE PARALYSES OF HYSTERIA. 

The case to which I drew jour attention at my 
last clinic is here again, a girl, rather wanting in the 
signs of sexual ripeness, although sixteen years old. 
You will recall the fact that she lost the use of the 
right arm because of having been alarmed. The 
scare brought on what every woman knows as an 
attack of hj^sterics — our ancestors called it the vapors. 
The girl cried and laughed by turns, and then had a 
slight fit, on coming out of which she could no longer 
lift her right arm, or rather she could lift it but a 
few inches. On finding this to be the case, she grew 
much concerned, and by and by could not lift it at 
all, the idea that it could not be raised helping, as is 
apt to be the case, to make the trouble worse. There 
seems to have been no deceit, but perhaps the first 
feebleness may have been slight, and the power of 
her belief in her want of force great, and this is 



14 DISEASES OF THE NERVOUS SYSTEM. 

rather the more likely since, as you saw, I raised the 
arm and said, "Now you can keep it up," which she 
did. You see that it seems again palsied. A new 
order restores it, and she lifts it without much effort, 
having won a belief in my being able to aid her. I 
send her away with a lightly uttered word or two as 
to the use of the hot iron, if she again loses power. 
The warning may answer or may not. "We had a 
case very like this two years ago. I believe it got 
well. 

We see here among the ill -fed, needy, and worried, 
a good many cases of hysterical loss of power, and I 
meet a yet larger number among women of the upper 
classes, where the disease is caused by unhappy love 
affairs, losses of money, and the daily fret and weari- 
someness of lives which, passing out of maidenhood, 
lack those distinct purposes and aims which, in the 
lives of men, are like the steadying influence of the 
fly-wheel in an engine. 

It is my present wish to speak of some of the many 
kinds of hysterical paralysis, and to dwell far more 
freely on methods of treatment than upon minute 
details in the natural history of these disorders. I 
do this chiefly because as regards treatment I hold 
very positive opinions, and because these opinions 
have, I believe, been amply justified by happy re- 
sults, some of which are familiar enough to those 
who have followed my practice. 

The group of instances of lessened power which I 
shall here discuss will include the usual forms of hys- 
teric paraplegia and hemiplegia, and that which I 
shall call double hemiplegia. I shall not attempt to 



PARALYSES OF HYSTERIA. 15 

cover the whole range of hystero-palsies, but seek 
chiefly so to define a certain number as to allow me 
to speak of their treatment. I shall also describe 
four forms of seeming loss of power, only one of 
which is essentially- hysterical in nature, and not 
found elsewhere with the same features. I allude to 
hysterical motor ataxia. 

The others are palsy from the rule of an idea, gen- 
eral paresis, and consciously mimicked palsy. 

All three of these may be and are seen outside of 
hysteria, but they find in it a fertile soil, and are none 
the easier to treat when they are masking in this 
disguise. 

One of the chief troubles in clearly knowing and 
in dealing with all of these forms of disease is due to 
the fact that in most cases, and to some extent, they 
may exist in union. The case of palsy may be partly 
real, partly pure weakness, partly loss of power from 
want of belief in being able to move ; or conscious 
mimicry may be added to palsy or to the forbidding 
influence of a regnant idea, or to the true hysteric 
palsy may be joined ataxy of motion. For such vex- 
ing marriages of disorders, and for their offspring of 
doubt, we must be ready and watchful. They make 
the true limits of hysteric lack of power hard to de- 
fine, hard to treat, full of surprises, and unfailing in 
interest and variety. Take this for an instance : You 
have a case of extreme hysteric paresis to treat. As 
a rule, it is readily cured. You predict a clear and 
happy future. As time wears on the mere weakness 
is gone, the limbs are plump again, the cheek red, and 
then you may find, if you have not been careful, as I 



16 DISEASES OF THE NERVOUS SYSTEM. 

have found, that hidden in the mere weakness there is 
a distinct amount of motor palsy — a mild, one-sided, 
loss of power — a true hysteric palsy, and not at all 
easy to cure. I shall pick for you, out of my note- 
books, cases of each of the forms of disease I have 
just spoken of, and shall try to make plain to you 
how I treat them. There were once no cases so much 
dreaded by me. There are now none to which I go 
with so much pleasure. I am sure that I treat them 
to-day with a success I could not once have gained, 
and I think that what success I have had has been 
due to more exact ideas as to what is needed, and 
that unflinching purpose and action which grow out 
of distinct views. 

Let us take first a case of paraplegia — less common 
than hemiplegia and more difficult to relieve. The 
example I shall quote for you is the more interesting 
because of its having ended in death. 

Mrs. C, ddt. 36, a strong woman, and in all ways 
well, lost by sudden death a child and her husband. 
Thus having cast on her the care of a large estate, 
loaded with many burdens, she began to show excess 
of anxiety as to her affairs, and from being sweet of 
temper became abrupt and full of unreasonable doubt 
as to her advisers. The worry brought with it speedy 
loss of blood globules, and as she was a woman who 
flowed very fully each month, all these causes together 
began to tell. This is the kind of thing we see much 
of in medicine. The books say this, that, or the other 
causes hysteria. In practice it is usual to find two or 
three causes — acting to assist one another. This 
woman was quite ready for an outbreak of some form 



PARALYSES OF HYSTERIA. 17 

of nerve trouble, when of a sadden she met the final 
blow in the form of a telegram. The news it bore 
was neither good nor ill, but by evil luck the writing 
looked like that of her dead, husband, and she began 
to laugh with that strange want of appropriateness 
in emotional expression so common in the nervous. 
Awaking next day her legs seemed heavy, which 
caused her great alarm. At once, as she told me, the 
fear of palsy arose in her mind, and haunted her the 
more as, day by day, the feebleness grew worse. She 
was in Germany when taken ill, and seems to have 
been looked upon as suffering from an organic mal- 
ady, for she was treated with nitrate of silver and 
the hot iron. Then as she failed to get relief any- 
where, she was sent from one spa to another with a 
skill which as yet we are fortunately far from being 
able to reach. 

St. Moritz, Schwalbach, Vichy, Loueche, and 
springs of lesser note, had each their turn, after the 
European fashion, until, in despair, she was carried 
back to America, where I saw her often and until 
the close of her life. 

This was what I found : A woman of 35, height 5 
feet 2 inches, weight 170 lbs., flabby, and thin blooded, 
with healthy heart, lungs, and kidneys. On the left 
side of the vagina was felt a tumor about the size of 
a walnut. It was very tender, and firm pressure on it 
gave rise to nausea and distress down the left leg. I 
had no doubt that this growth was a displaced ovary, 
but, despite this change of place, the left iliac fossa, 
both the skin and the parts reached by deeper pres- 
sure, was tender to touch. Was it ovarian tender- 

2* 



18 DISEASES OF THE NERVOUS SYSTEM. 

ness ? Hardly, in this case. I have been told by Dr. 
Groodell that he has seen this same sensitiveness in 
other instances where the ovary had been displaced, 
and probably too much has been and is made of this 
symptom. The tenderness in Mrs. G.'s case was iso- 
lated, as is not unusual, and all about it up to the 
waist and down to the feet the body was without 
sense of touch or pain, or of heat and cold. In 
tracing this defect upwards it was found to cover the 
left breast, but this was so to-day, and then to-morrow 
it was less, the upper limit ranging from the navel to 
the left armpit. 

Motor power was failing when I first saw her, but 
this had been the case before, and had been followed 
by a change for the better. 

The plan pursued in treating the case was one to 
which I groped my w r ay a few years ago. My patient 
was very thin blooded, and yet very fat. Such cases 
for some reason not clear to me are more hard to 
redden than are those of thin people in like states of 
blood. But if you can safely cause these persons to 
lose flesh, as they are helped to remake it, you may 
sometimes redden them with ease, and to raise the 
number of blood globules to the normal is usually to 
lift a woman above that low level of health, which 
is one, at least, of the factors of hysteria. 

Mrs. C. was, when first seen b}^ me, sitting up most 
of the day, and sewing, writing, and the like, when not 
too nervous. I put her in bed, and employing as a diet 
milk alone, mixed with a little rice-water or barley- 
water, I began to lessen the amount given, until, 
using less than a quart a day, her weight fell off at 



PARALYSES OF HYSTERIA. 19 

the rate of about a quarter to half a pound a day. 
When she showed signs of weakness I added beef 
soup to the diet for a day or two, and thus in one 
month brought down her weight some twenty-four 
pounds. This could not with safety be so quickly 
done unless the patient were kept inert and supine. 
Then the milk w r as by degrees increased. Raw beef 
and vegetables were added, malt extract was used 
before meals, a little red wine or champagne was 
allowed, and iron was given freely, the feeding being- 
frequent. When I made the increase in diet I began 
to arouse sensation by the use of the wire brush and 
induction currents. 

Now in common palsies, or in those from nerve 
wounds, feeling is apt to come back first, motion last; 
but in hysteric palsies, as I think, the gain in active 
motion may go on, and even reach a useful amount 
while yet the lack of feeling rests as it was when 
the treatment began. Just this change took place 
in Mrs. C. : She grew brighter, and more happy, 
gained in color and flesh, and began to move her legs. 
In a month after she reached full diet she could walk 
with some trouble, and about this time the sense of 
touch showed signs of betterment, but the power to 
feel pain was unchanged, and, in fact, was never com- 
plete in the left leg. 

Next began a plan of steady, urgent calls upon her 
for increase of the use of her limbs, so that before 
long she was able to walk out of doors. At this point 
I fear there was a mistake made in the treatment. 
Thinking the battle won I pushed her too hard, and 
one day after walking much further than usual she 



20 DISEASES OF THE NERVOUS SYSTEM. 

felt an excess of fatigue. Returning home she gave out 
of a sudden, and the morning after was again hardly 
able to stir either leg. I may pause here to repeat 
as to this matter a warning I have often given. It is 
to urge on you the utmost care as to allowing a hys- 
terical patient on the way to health — I mean, of 
course, one who has lost power — to do more each day 
than fulfil the ordered task of that day. Most cases 
of hystero-paisies are easily tired, and it is almost 
sure to be the case that they cannot make a long 
effort without showing the effect in some way ; more- 
over the mental results of extreme tire are to be 
feared, because any positive, real sensation is apt to 
become the peg, so to speak, on which the patient 
may hang the complement of a larger and less real 
sensation. 

More slowly this time Mrs. C. got back some con- 
trol over her movements, but at a certain point the 
gain ceased, and we made no further progress, nor 
did this surprise me. Hysterical paraplegia is, as I 
have said, more hard to cure than any other hysterical 
trouble except, perhaps, multiple contractures, and I 
felt that I had done well to win what I had won. 

About six months later this lady died after a brief 
illness, which seemed to me more like a sudden and 
complete palsj^ of the pneumogastric nerves than any- 
thing else. No examination post mortem was allowed. 
I have known three deaths in hysteria ; all were ab- 
rupt, and two were due to acute congestion of the 
kidneys. 

Of that more common type, the palsies of one side 
of the body, you have seen a number. They are 



PARALYSES OF HYSTERIA. 21 

more frequent than paraplegias; less hard to cure, 
but quite lasting enough to make you cautious as to 
what you predict about their future. Where they 
occur in the feeble and thin-blooded, who have by 
degrees grown emotional, tearful, and weak of will, 
you may have more hope of helping them than if 
they are met with in robust people of non-emotional 
type, in whom the usual emotional elements which go 
to build up this temper of mind are wanting, or are 
small in amount. The former offer through the re- 
lief of their nutritive defects chances of obvious 
nature; the latter are apt to be bright or even able 
women, who enlist their mental forces in behalf of 
their symptoms, and treat the hated charge of being 
hysterical with utter scorn. 1 

I cannot leave this subject of hemipalsies of hys- 
teria without a few words as to the ordinary type of 
this disorder. 1 shall therefore sketch for you some- 
what briefly the chief symptoms of hemiplegia of 
hysterical origin. 

This disease may come on slowly, and during the 
varied course of a case of hysteria, or it may arise 
abruptly, in an instant even, in women known or not 
suspected to be hysterical, owing to some profound 
emotion or to an accident, such as a fall or a wound. 
It is often of such insidious development that its 
presence, when mild, is a thing rather to be found by 

1 I ought, perhaps, to add that these women are usually mohile 
and excitahle hy nature, prone to laughter more than tears, so that 
it is hardly exact to say they are not emotional. Their form of too 
ready emotional disturbance lies merely in an unusual direction 
for the victims of hysteria. 



23 DISEASES OF THE NERVOUS SYSTEM. 

looking for it than of such a nature as to be forced 
upon the attention of the observer. It is excessively 
rare to see it as complete as we see a hemiplegia of 
organic origin. Nearly always, I might venture to 
say always, it is associated with some loss or distur- 
bance of sensation. More often this latter symptom 
is the dominant one, and the lack of power merely 
amounts to a paresis or incomplete palsy. 

Unlike the hemipalsy of cerebral and organic cause, 
hysterical half-palsies involve more or less all of one 
side of the body, excepting the face ; but in a few 
rare cases the neck is distinctly affected, while usu- 
ally when the case is incomplete, it is the leg which 
suffers most, both as to sensation and motion. 

Apart from the fact that the face escapes there are 
other symptoms which differentiate these losses of 
power from those which are due to clots or emboli, 
and a knowledge of which enables us to diagnose the 
case with sufficient ease, as arising from hysteria. As 
to locality, in Briquet's cases there were 70 on the left 
to 20 on the right; in my own note-books, I find the 
proportion as 4 left to 1 right. The amount of loss 
of power is often quite definite, but in other cases it 
varies in degree within wider ranges than we see in 
palsies of organic birth. 

Sensation is disturbed, lessened, or lost either 
throughout the one half of the body or in varying 
amounts over this space, and in the face as a rule less 
than elsewhere. In rare cases, the sensibility improves 
very near the middle line of the body. In some in- 
stances no feeling exists ; more often sense of touch and 
power to localize sensations remains with profound 



PARALYSES OF HYSTERIA. 23 

analgesia, and often also with lack of power to tell 
heat from cold. In bad cases the eye loses its keen- 
ness of perception, and the color sense is blunted 
while smell and taste alike suffer. 

The ovarian region on one side is apt bat not cer- 
tain to be tender, either on the surface or upon deep 
pressure. Charcot and Dr. Buzzard both state that 
the patellar tendon reflex is exaggerated on the side 
of the palsy, and the latter that the ankle clonus may 
at times be met with. In the last three cases I have 
seen of hysterical hemipalsy the patellar tendon re- 
flex was increased on the affected side. In two others 
it was notably lessened, as was the case in the girl 
present at my last clinic, where it was only possible 
to be sure that this sjnuptom existed at all by grasp- 
ing the muscles with one hand while the blow was 
struck. In another case the flexors responded and 
not the extensors ; and in yet another, with an exag- 
gerated reflex, there was also a sharp contraction of 
the adductors on both sides. 

These symptoms, with the history, should make 
the diagnosis an easy one, and I may add that while I 
see many mistakes made, owing to confounding hys- 
teric paraplegias with those of organic cause, I rarely 
see such confusion as regards hysteric hemiplegia. 

The following case, now in the Infirmary, may 
serve as a fair type of this form of paralysis. Miss L., 
a fine, large, ruddy woman of 26 years of age, owes her 
hemipalsy to the shock of a fall from affluence to the 
need to support herself by giving lessons in music. 
Then a succession of deaths fell upon her household, 
and at last one day, while teaching, she fell asleep, as 



24 DISEASES OF THE NERVOUS SYSTEM. 

it were abruptly, at about 7 A. M. She was aroused 
enough to be taken to bed, and there remained in 
what seemed to be profound slumber, thirteen hours. 
After this unusual trouble she grew more and more 
hysterical, and at last came under my care. Her 
organs are, in general, healthy; but she has this 
curious peculiarity, of which she seems quite un- 
aware. The pulse varies from 80 to 95, but the 
respiration, without seeming to be hurried or dis- 
tressed, is never less than 40, and is often 60 to the 
minute. 

She has considerable loss of power, with incom- 
plete analgesia, defect of thermal sense, and preserva- 
tion of touch. The face is scarcely affected at all, 
and the senses of sight, smell, and taste are intact. 
What is curious is, that there is no ovarian tender- 
ness on either side, and that the analgesia varies 
daily, almost hourly, as to extent, place, and amount. 
A mustard plaster or blister, or, more remarkably, a 
rhigolene freezing, will often restore feeling over a 
large space for a few hours or for days; but inva- 
riably the next menstrual flow undoes whatever 
good may have been done. I tried the " metal cure" 
in this, as I have tried it over and over in other and 
worse cases; but although from it, or from glass, 
cork, wood, or what not, I have obtained many times 
a slight local change in feeling, I have never seen 
this complete, and have never once witnessed the 
phenomenon of transfer of the analgesia or anaesthesia 
to the opposite side — a phenomenon which seems to 
be undeniably frequent in the hands of as admirable 
an observer as Charcot. I ought to add that my col- 



PARALYSES OF HYSTERIA. 25 

league, Dr. Sinkler, has not been in this matter more 
fortunate than I, although lie lias, I believe, studied 
several cases from this point of view. The patient I 
have mentioned lias many other hysterical troubles, 
and being quite rosy and stout, will be a difficult case 
to deal with. It is interesting to learn that until this 
girl came here neither she nor her medical attendants 
were aware that she had any loss of feeling. 

The temperature of the left, the affected leg, is nor- 
mal, or the same as the other, and pin-pricks fail to 
bleed at any part of the limb where there is lessened 
feeling. The tendon reflex of the patella is remark- 
ably exaggerated on the palsied side, but there is no 
ankle clonus. Under use of good diet and tonics this 
girl is gaining color and weight, while by a succession 
of irritants, chiefly the wire-brush and induction cur- 
rents, the sensation has been more and more success- 
fully restored, so that the last menstrual flow has 
been less disastrous than usual. 

I shall not trouble you further with details of this 
the most common type of hysteric hemiplegia, but 
pass on to one of the forms not well described as yet, 
and which I shall, in advance, venture to call double 
hemiplegia. This, as we shall presently see, is not 
merely another name for paraplegia. 

Miss B., a sturdy, handsome girl, set. 16 years, had 
a series of ills one on another from time to time. 
The first sign of trouble was twitches of the ej^elids, 
and tears on reading ; then there was a pause of two 
years. The next disturbance was a noisy and obsti- 
nate hiccup, during which both iliac fossae became 
tender, and a single hypodermic use of morphia Avas 
3 



26 DISEASES OF THE NERVOUS SYSTEM. 

followed by convulsions. Next came hysteric loss of 
desire for food, nausea, pains in the left arm and leg, 
and spasm of the vessels in the left leg, so that it be- 
came white and cold. Up to this time she still walked 
out; but in the summer of 1878 the use of galvanism 
is said to have been followed by sick stomach and loss 
of power to stand. In the autumn she got rid of im- 
mense masses of hard feces, when all the symptoms 
improved for a time. The next winter was passed in 
bed, vomiting a good deal; eating little; the bowels 
very hard to move; the urine passed every hour. 
About this time also she began to shun light, and 
came at last to living, with covered eyes, in a dark- 
ened room. When I saw this young lady I was 
struck with the thorough type of the emotional hys- 
teric person she showed ; nor from the usual weak 
will to the usual love of sj^mpathy was there any tint 
wanting to the picture. I watched her for a few 
days without ordering treatment until I learned all I 
could of herself, her history, her home-life, her pur- 
suits, her ambitions, and her mental powers. Then 
a talk with a watchful nurse helped me further,- and 
I saw clearly that I had to do not with a clever 
woman who may be won over, and who is flattered 
by the tribute paid to her mind when you insist that 
to cure her she must be made to understand and 
agree with you, but with a child who to be made well 
had to be calmly and firmly ruled, and held day by 
day to rigid account. She was at once shut up, with 
a good nurse, and kept at rest in bed, not being 
allowed to use her hands even to feed herself. As 
she had been able to knit and sew, and be read to, 



PARALYSES OF HYSTERIA. 27 

and to receive many visits, the sense of the irksome- 
Bess of the treatment soon made her eager to do any- 
thing I wished. Then began a system of bribes. 
She was told that if she could learn to bear the light 
she would be able to be read to, but that the nurse 
could not be allowed to strain her eyes. It would 
have been easy to open the windows and say jou 
must bear the light, but if she herself gained this 
point of vantage, it would have the great value of 
being a self-conquest. In a few days I found the 
sunlight bright in her room. Then she was asked to 
overcome the habit of regurgitating her food. One 
or two scoldings, some show of disgust, and the pro- 
mise that she should soon feed herself if she obeyed 
my wishes, helped us through with this. There were 
relapses; but as I found she hated milk I felt forced 
to put her back on the milk diet we began with when- 
ever she threw up a meal, so that before long we 
heard no more of the vomiting; meanwhile the steady 
feeding and the use of massage, and local muscle treat- 
ment by electricity, began to show in a gain of flesh 
and color and firmness of muscle. She was now very 
weary of this unending quiet, and the time for educa- 
tion of the motor powers seemed to have come. Her 
loss of motion on the left side was very marked, and 
there was complete want of power to feel pain or to 
tell heat from cold ; yet I could not make out any 
loss of vision or of color-sense. The touch was not 
perfect, but she knew fairly well where she was 
touched, although she could not be tickled. 

As regards the pain sense there was one very curious 
point to which I have already alluded. As the needle 



28 DISEASES OF THE NERVOUS SYSTEM. 

came within an inch or two of the middle line of the 
body it was felt, and the better felt the nearer it came 
to this line; nor do I recall having met with this 
fact in any case of palsy from organic canse. The 
right side of the body was palsied in a less degree, 
and only as to motion, the leg far more than the 
arm. The same was the case on the left side as 
regards all the forms in which the functions were 
deficient. Now as this case grew better the right 
side became entirely well first, leaving the left hemi- 
plegia as before, so that I have reason to speak of 
the whole loss as being due to a double hemiplegia. 
In other cases I have seen a general loss of sense and 
motion, and observed entire relief on the right side, 
leaving only a hemiplegia of the left. 

My patient had some wasting of the left leg, and 
less good electro-muscular reaction on the left, but 
no pain on that side from any form of current. The 
tendon reflex below the knee-pan was good on the 
right; and also on the left; but what was new to me 
the jerk was sometimes due to the extensors, and 
sometimes due to the flexors, the extensors in the 
latter case not seeming to move at all. Here was 
another of the oddities of this most strange disorder. 

As is usual she moved her limbs best while in bed, 
and showed, when I came to let her sit up, or stand, 
the loss of balancing power, which is seen in all 
grave hysteric palsies, and is, indeed, almost a sure 
sign of the parentage of the disease. 

I have often asked you to note another point which 
this case showed very well. You ask the patient to 
raise the leg. It is lifted an inch ; you insist on 



PARALYSES OF HYSTERIA. 29 

effort, it is lifted higher; or if a great effort be made 
the motion consists of a series of lifts and pauses. 

The reliefs of distinct hystero- palsies are said to be 
often abrupt. Under emotion or return of the men- 
strual flow, or on an order from some one, the patient 
gets well. I must say that in hystero-hemiplegia 
and paraplegia, with loss of feeling, I have not been 
so happy as to see these delightful cures. In hysteria 
with mere paresis, in the palsies from belief, or from 
a ruling idea, I have seen such results many times. 
Neither do I believe that all hysteria is after a time 
within control of the sick person ; nor that she can 
in all instances run away in case of a fire, according 
to a popular medical belief. In fact I have now in 
my care a lady who was so tested by chance, and 
who utterly failed to do more than fall down in her 
effort to escape from a house on fire. 

In fact profound emotions may work either way 
for good or for ill, and no human sagacity will suf- 
fice to enable us to predict results. The evil is quite 
as likely to be prominent as the good, and at all 
events you may rest assured that emotions are some- 
what unmanageable and unreliable as therapeutic 
agents. 

I have felt the need to say this, even if too briefly, 
because I must add that the cures of these cases are 
to be made by a slow, steady, hopeful training of the 
will powers through every-day effort, which needs 
some caution not to err in the way of excess. A 
little nervousness is a bad sign, and it is well each 
day to attempt a very little — no matter how little if 
only we succeed, and can make the patient see it. I 

3* 



30 DISEASES OF THE NERVOUS SYSTEM. 

shall in another place be more precise as to the means 
used. Enough to say of this case that it went on 
slowly gaining ground, and was under my care a year 
before the patient could walk well enough on crutches 
to go home with a cheerful future. It was not a 
brilliant case, and it taxed nurse and doctor to the 
uttermost — a case urged and scolded, and teased and 
bribed, and decoyed along the road to health ; but 
this is what it means to treat hysteria. There is no 
short cut ; no royal road. 

Let us take another case. It was as much like the 
last as it could well be. The patient, Miss C. P., set. 
18 years, the child of wealthy parents, came to me 
last year from Indiana. The motor losses were very 
remarkable, and, as in the last case, it was the left 
side which suffered most. She was unable to lift the 
left leg, or flex or extend the foot, so that below the 
knee there was motion in the toes alone. The left 
arm preserved all movements, but all alike were fee- 
ble. The right side was more symmetrically disor- 
dered, so that almost every muscle of the leg and arm 
was partially paralyzed. Sensation was lost for pain 
on the left side, save as to the belly and breast, where 
it seemed to be good, while in the face and neck it 
was lessened. Sense of temperature was more abso- 
lutely lost over the whole side than is common ; and 
touch, not quite lost anywhere, was disturbed or les- 
sened in irregular spaces. On the right side sense of 
pain was lessened in the arm and lost in the leg, while 
touch and the thermal sense were well preserved. 
There was one matter in which this case differed from 
the last one, and this changed my whole manner of 



PARALYSES OF HYSTERIA. 81 

dealing with the malady. My new patient was a 
clear-headed, well educated girl, who once had had a 
vigorous will. She was described to me as unselfish, 
thoughtful, and intelligent, and as a woman only 
brought down to a state of hysteria by long illness 
and the want of helpful advice at the right moment. 
She was emotional and ashamed of her tears, and 
honestly hated the whole matter of sickness. You 
will see such hysterical women. You will see others 
whose minds are like the back of a piece of needle- 
work with a baffling absence of pattern — women 
with a low, whining, bleating voice that is by itself 
a tell-tale of the kind of will-less ataxia which seems 
to cripple the mind no less than the body. These 
are the hard cases to relieve. But to return to my 
more favorable case. I tried to make her see how 
much the defects of body have to do with those of 
mind, and therefore the need to begin by building up 
the body anew. When, after a time, the limbs began 
to round, and color to come back to her pallid cheek, 
I set her to thinking how far the early troubles might 
have been within her control. I assured her that, 
although she could not now overcome at once the 
results due to habitual failure of self-control, repeated 
efforts would surely end in success. She was told 
that it was like the case of a bad temper, easy to hold 
in check at first, but if long nnheld at last uncontrol- 
lable. It is not hard to open this point of view to a 
clever woman. You urge this idea from day to day ; 
you ask her to try your way. She says she has done 
so, and then you point out that with ill health success 
was out of the question, while with rising health it 



32 DISEASES OF THE NERVOUS SYSTEM. 

might be easy. At last you get her to promise to 
fight every desire to cry, or twitch, or grow excited. 

Above all, you teach her the priceless lesson for a 
"woman of the value of moods, of the ease with which 
she can get herself into a state of dangerous tension, 
of the necessity of learning, not how to bear a thing, 
but how to approach the idea of bearing it in a state 
of calm. It is a long sermon, but I can only give 
these few pregnant texts. It is always apt to win 
with a woman of intelligence, and the fools are to be 
dealt with by other moral drugs than these, or the 
honest pill must be gilded with timely flattery or 
such better motives as may help it to find the 
woman's conscience, if that is to be stirred at all. 

By and by, as one symptom after another gave 
way before her efforts, she became more and more 
sure that I must be right as to all ; and I have seen 
few cases gain ground with equal speed. Neverthe- 
less a whole year was needed to make her well able 
to take up afresh her full round of social and house- 
hold duties. In fact, even with the best of self-help 
from the patient, the cure of any one of these cases 
is a long and arduous course of education. 

Before leaving the subject of hysteric palsies I 
would say a few words as to the electric reactions. 
In most cases, and early in nearly all, the muscle 
reactions are normal ; but after a time, and in most 
old cases, these are less good than in health ; nor do 
limbs long palsied fail to shrink somewhat, while 
marked wasting is rare. When there is loss of 
motion and of feeling, Duchenne's axiom is correct ; 
that is, we have then normal electric reaction of 



PARALYSES OF HYSTERIA. 33 

muscles and absence of all sensation of pain from the 
most severe currents. In some early cases I have 
seen a state of things not elsewhere spoken of. I 
saw it last week in a chronic case of horrible 
rhythmic spasms of the arms, with palsy of sense and 
motion in the legs. Dr. Yarrow, the attending phy- 
sician, studied with me the electric state, which was 
curious. When with slow or rapid breaking of cir- 
cuit (induced currents) we tested the leg muscles, the 
poles, even with currents unbearable by us, caused 
no motion until they had been steadily applied for 
from two to three minutes over any one muscle ; but 
the reaction of nerve and muscle, one pole on each, 
Avas somewhat more rapid, although still very slow. 
What we saw was in reality but an exaggeration of 
the delay in arousing muscles which we see in health 
and in other forms of disease than hysteria. 



34 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE II. 

HYSTERICAL MOTOR ATAXIA— HYSTERICAL 
PARESIS. 

The form of disorder to which I shall first direct 
your attention in connection with the false palsies of 
hysteria is the motor ataxia of this disease. It is 
necessary here to be extremely precise, because, as 
you will see if you read Briquet's admirable study of 
hysteria, he also describes a form of hysterical motor 
ataxia. 

Ataxia, as you well know, means merely disorder 
or irregularity, and when therefore we speak of loco- 
motor ataxia we mean only disordered movement, 
and not of necessity enfeebled movement. The cause 
of the disorder or incoordination thus introduced into 
motor functions may vary. 

In hysteria, so far as I know, there are two forms 
of motor ataxia independent of those associated with 
vertigo. That described by Briquet and Lasegue 
seems to depend upon a loss of sensation in both skin 
and muscles. In Lasegue's case the girl was only 
able, the eyes being closed, to move the limbs which 
were still sensible, but was totally unable to move 
the anaesthetized parts or to know where they were 
when moved by another person. While seeing, she 
could walk readily and even without looking at her 



HYSTERICAL iMOTOR ATAXIA. 35 

feet. 1 In other and similar cases there is merely a 
lack of coordination in complex motor acts. 

There is, however, another and a very interesting 
form of hysterical motor ataxia which is, I fancy, 
rather rare in its most perfect type, and which may 
without due care be taken, as Duchenne's disease was 
long taken, for some kind of paralysis. 

The trouble I am about to speak of I find to be in 
some of its degrees very common in hysteria — to co- 
exist with many hysteric palsies or paretic states, and 
sometimes, though rarely, to be the prominent malady, 
with almost no loss of voluntary power. 

The hysterical ataxic patient of this class, and I 
shall consider first the nearly pure case, has full feel- 
ing, or may have it, and is quite well able to use the 
limbs more or less freely while lying down. When 
she begins to sit up or kneel or stand, the lack of 
coordinate muscular movements becomes at once 
visible. 

Instantly the patient begins to fall to one side, a 
voluntary effort to redress the disturbed balance 
results in a partial fall to the other side or back or 
forward, as may chance. The patient seems to be 
"unable to judge of the extent to which the balance is 
lost, and also to determine or evolve the amount of 
power needed to overcome the defect. The abruptness 
of these efforts at redressing the loss of equilibrium 

1 There may be in this something of habit. In the few cases of 
Duchenne's disease which I have seen in women I have been 
struck with the way in which, as their garments habitually hide 
the feet, they managed to dispense with the guiding sight of these 
parts. 



36 DISEASES OF THE NERVOUS SYSTEM. 

appears to show an absence or defect of the usual 
antagonistic activity of opponent muscles. I am 
inclined to suggest as a reasonable theory that per- 
haps a large share of this difficulty may be due to a 
slowness in volitional acts by reason of which the 
mandate reaches the muscle too late to be of ready 
service. This is by no means unlikely, for in some 
hystero-palsies I have measured and proved the re- 
tardation of nerve conduction. Slowness in learning 
the need to move a muscle and slowness in moving 
it would give rise to just such incoordinate action as 
these cases exhibit. The lack of orderly movement 
is chiefly in the neck and trunk, and is made worse, 
like all disorder of motion, by excluding the guiding 
influence of vision. 

This very interesting form of incoordination in 
muscular acts is limited for the most part to the more 
complex movements. It is seen little or least in 
single limb motions, better in sitting or kneeling, 
better still in standing, and best of all in walking. 
It is not due to weakness because it exists in cases 
strong enough to sit, stand, and walk firmly, if only 
power were needed to the efficient accomplishment of 
these acts. Also, while you may find it with general 
or local lack of surface feeling, it is not due to this, 
because anaesthesia of the skin is, in the hysterical at 
least, incompetent to cause ataxia of motion. In the 
confusion and odd grouping of symptoms in hysteria, 
the trouble I have described is apt to be overlooked 
or attributed to coincident conditions. It is, there- 
fore, fortunate to find uoav and then cases in which 
this form of motor disorder occurs almost alone, so 



HYSTERICAL MOTOR ATAXIA. 37 

that we have a chance of studying it without being 
embarrassed by other symptoms. 

I believe that this ataxic state is common in grave 
hysteria, and is to be found often enough in milder 
cases. I think also that some of the cases which are 
attributed too promptly to muscular anaesthesia will 
be found to be free from that defect, and to be due to 
other causes than those to which Briquet has attri- 
buted them. Perhaps it may be that conscience of 
locality will prove a differentiating test, since it is 
said to be lost in the hysterical ataxia of Briquet, 
and is certainly not lost in the form I have here 
delineated. 

I do not think one could readily confound this 
ataxia of movement with anything else unless it be 
with one of the rarest of the forms of hysterical 
spasm. The following case is an apt illustration of 
this latter disease which might perhaps be well de- 
scribed as alternating spasms, the action of the flexors 
calling the extensors instantly into movement, and 
these in turn summoning the flexors into like activity. 
These semi-spasmodic motions were the more curious 
in the last case I saw because of the general and pro- 
found paresis which made every volitional effort ex- 
cessively difficult. I may add that there was also a 
contraction of the right leg and a left hemi-anaesthesia 
with conscience of place. 

The patient, when seated and held up, or even 
when the head alone was unsustained, showed the 
following symptoms: The head or body was pulled 
to one side. At the limit of this motion, or before 
that was reached, it was violently jerked over by the 



38 DISEASES OF THE NERVOUS SYSTEM. 

opponent muscles, as if their stretching were the sig- 
nal for an explosive act of power. At once or in a 
moment the other muscles acted in like fashion, and 
so the head or trunk was thrown about in a straDge 
and disorderly manner so long as the patient remained 
upright. The same type of movement extended to 
the legs and arms. These acts were certainly of 
volitional birth, but they were, so to speak, convul- 
sive renderings of natural acts, and were sometimes 
very violent. 

I may add that, notwithstanding the complexity of 
symptoms, with such a loss of memory as necessitated 
an entire re-education, this girl became entirely well. 

In place of giving you types of motor ataxia with 
palsy I shall prefer to choose one now in my care, and 
which has the least share of palsy for the largest 
share of incoordination of the muscles. 

Miss B., set. 20, Kentucky, of healthy, living 
parents, in August, 1876, while going home from the 
Centennial Exhibition, caught a slight cold, out of 
which came complete loss of voice for seventeen 
months. In its return it came and went abruptly, 
and was well to-day and gone to-morrow. In Sep- 
tember, 1871, at the Hot Springs, Arkansas, after a 
good deal of worry, she is said to have had head- 
ache and dizziness, after which of a sudden she lost 
speech, and became unconscious, with her jaws firmly 
locked. The legs and arms were seized with spasms, 
and when they became better had nearly lost touch- 
sense, and did not feel pin pricks. This attack ended 
in weakness and fever, with cold feet and loss of power 
to swallow even saliva. After three weeks she re- 



HYSTERICAL MOTOR ATAXIA. SU 

gained speech, and then again relapsed. She was said 
to have had a typhoid fever, which does not seem 
likely. 

About the fifth week she was found to have lost 
power in the legs. The loss is described as having 
been nearly entire, but by March, 1879, she had re- 
gained a good deal of motion. Since then she has 
been at a standstill. 

In October I saw Miss B. in bed, a dark-skinned, 
rosy-looking girl, without the least turn to tears or 
undue emotion. I should only have said that her 
manner was quick and excitable. She certainly had 
none of the usual furtive look, and small deceitful- 
nesses of some hysterical girls. Neither was there 
any loss of tendon (patellar) reflex, and the senses of 
pain, of touch, and of heat were perfect. 

While in bed Miss B. moved all her limbs somewhat 
slow'fy, but with a great deal of power ; the lift of 
the leg was done in jerks, as by distinct orders of will, 
but she showed none of the tremor and twitching of 
face and tearful look so common in hysteric girls 
called on for an unusual effort. When held up on 
her knees, she swayed to and fro, always falling if 
not assisted. When somewhat later she could stand 
up, the motor disorder showed still better. From 
head to foot every muscle used to preserve the upright 
posture gave way momently, and was braced again 
by distinct acts of will. The rocking motion so 
caused was curious to see. A slight push was sure 
to upset her, as if she was unable to provide in time 
enough of power to resist the shock and restore the 
disturbed balance. If I warned her of the comingr 



40 DISEASES OF THE NERVOUS SYSTEM. 

shock, she did far better. The touch of a hand 
greatly aided her, and the closing of her eyes made 
things worse. Nor did Miss B., when standing, ap- 
pear to have the least idea of her balance being in 
danger until the sway of her figure became extreme, 
when she caught herself up, and with an effort re- 
gained her erect position only to fall to the other side. 
There seemed to be a lack of appreciation of the fail- 
ing balance, and a slowness in redressing it when lost 
or in peril. When added to this we have complete 
loss of feeling, when skin, bone, joint, and muscle 
share alike in this respect, we have, of course, a still 
more complete and a different form of want of power 
to preserve the upright posture, but this is the cha- 
racter of the trouble spoken of by Briquet and others, 
and I wished to make it clear that there were causes 
of motor ataxy which did not of need involve any 
lack of tactile sense. 

In Miss B.'s case little was needed beyond training 
the weak and inapt muscles, because she ate and 
digested well, slept soundly, and was free from pain. 

My first step was to point out to her that, after she 
had made an effort which seemed extreme, another 
forth-putting of will would add to the previous result. 
This seems a simple thing to make clear; but, if you 
can convince your patient of the fact, it is of great 
service, because then you go on to point out further 
that, perhaps, by a series of trained and aided efforts, 
there may be won, bit by bit, a full power of motion. 
To lodge this idea in a woman's mind is at once to 
widen the horizon of hope. How much you gain by 
it depends a little on whether your patient is clever 



HYSTERICAL MOTOR ATAXIA. 41 

and wants to get well, or is silly and prefers the role 
of hysteria ; but, after all, the whole mode of treat- 
ment rests on a study of character, or of character 
and hysteria, and a moral diagnosis is the first step 
to take. 

With Miss B., at a standstill for months — bright, 
clever, longing; for active life — the idea was as a whole- 
some ferment. The nurse now began to train her 
while in bed to move the legs, one at a time, very 
slowly, but in larger and larger movements, with 
intervals between of a minute or more. 

An order is given to lift the leg ; if it be too weak, 
a finger beneath the ankle aids it, but no attempt 
must be let to fail utterly; as she gets on, the orders 
are to be obeyed more quickly. It is easy to sketch 
out for one's self what such a system should be in its 
details. After it has gone far enough, the patient is 
seated in bed with some support to her spine, and is 
trained to move the head freely. When, in Miss B.'s 
case, she was put on the edge of the bed seated, the 
motor ataxia began to show, so that it took some 
time to overcome this trouble. The next step used 
with me to be a lesson in walking, but of late I 
find it better to teach the girl to creep, which is an 
easy and natural mode of training for the walk. The 
patient has pads tied over her knees, and, lying flat 
on her face on the floor, without skirts, has around 
her a folded sheet. At an order, she tries to rise, 
helped by the lift of the sheet-belt held by the nurse. 
When she is able to do this, and can gather her legs 
and arms so as to make herself a quadruped, she is 
taught to balance herself, every effort being assisted, 

4* 



42 DISEASES OF THE NERVOUS SYSTEM. 

when needing help, by the nurse standing above her. 
The progress to creeping is easy ; then comes the 
lesson of kneeling and pushing a chair ; and last that 
of standing in a corner or by a chair. You see that, 
following nature's lessons with docile mind, we have 
treated the woman as nature treats an infant. For 
aid in walking we have three devices : the expensive 
wheel crutch, which can be easily imitated by a clever 
carpenter, being merely a framework with rollers so 
arranged that it includes crutch supports. Next, if 
need be, I use a device which may be common, for 
all I know, but which I have not seen elsewhere. It 
is a pair of crutches with a stout half-hoop of metal 
between and in front of the two. This gives a solid 
support, and, in ataxic cases, is very useful as giving 
a sense of security, and therefore of confidence. 
This crutch-frame is soon replaced by a pair of sup- 
ports, the bases of which are about seven or eight 
inches long and two broad. They may be made like 
the lower half of a crutch, or have two columns of 
a support set in the base, or may be a single cane with 
broad base ; the top in any case should have a double 
curve so as to lie easily in the line of the natural slope 
of the palm when resting on such a support. A rubber 
footing gives a little elasticity and a good hold on 
any form of flooring. With such a broad base of 
support, it is quite pleasant to find how soon the 
patient learns with its aid to balance herself. A 
third form of support which I devised two or three 
years ago is of use in hysteric or in any form of 
hemiplegia. If the left arm be too feeble to aid the 
left leg by grasping a crutch, I resort to the following 



HYSTERICAL MOTOR ATAXIA. f 43 

arrangement. On the lame side a crutch, having 
above an unusually deep hollow to receive the armpit, 
is fastened to the arm by two straps or by a glove 
riveted to the hand-piece of the crutch, so as that the 
hand once slipped into it is pretty firmly held. From 
the crutch a double metal bar curves forward and 
towards the sound side, and ends in a handle which 
is grasped by the sound hand and carried forward by 
it. I have found these supports most useful in many 
forms of weakness. In making them or having them 
made, pray remember that they should be made 
light ; most crutches are too heavy. 

With regard to Miss B., I may add that she got 
well in two months so as to walk unhelped anywhere, 
and that she is now free from pain and nervousness. 

Before leaving the subject of hysteric motor 
ataxy, I wish to add yet a single illustrative case in 
order to show that ataxy, connected with hemiplegia, 
may affect a single limb. Such cases approach in 
character the choreoid troubles which accompany or 
follow certain cases of hemiplegia from organic dis- 
ease of the brain, and afford yet another of the 
shadowy resemblances which link the various forms 
of hysterical disorders to their analogues of more 
definite parentage. Miss C, set. 30, grew up in luxury 
and ease, subject to what she somewhat indefinitely 
described as spells of prostration with nervousness. 
At the age of twenty a sudden death in her family 
caused a sharp convulsive attack, followed by a brief 
period of insanity, lasting in all three weeks. Three 
years later her family fell into almost absolute want, 
and she began to work hard in the effort at self sup- 



4i DISEASES OF THE NERVOUS SYSTEM. 

port, and then gradually failed in health, suffering at 
intervals from a variety of hysterical symptoms. 
These resulted abruptly in incomplete left herni- 
anassthesia, with great loss of power in the leg and 
lessened power in the hand and arm. 

With this report of her case she came to me some 
months ago. Except a very slight retro-flexion, 
there was no uterine trouble. Neither ovary was 
sensitive, but the spine in all its length, and the left 
side of the chest and the upper part of the belly were 
very tender — more to touch than deep pressure. All 
other organs were healthy. 

The hemi-ana3sthesia as to touch and pain was 
notable in the parts below the waist, and was incom- 
plete in irregular areas, which shifted daily. Pin 
pricks did not bleed in the leg. 

The hand and arm had good sense of touch every- 
where, but lessened pain sense chiefly on the radial 
aspect of the arm. The leg was almost motionless. 
The arm and hand could be used with nearly natural 
force, but were stricken with remarkable ataxy of 
movement without the least sign of spasm. The 
utmost concentration of will failed to direct the hand 
so as to enable it to grasp or manipulate an object 
once held. The limb would waver to and fro, and at 
last descend on the object with an effort which usu- 
ally carried the hand far to left or right. A certain 
abrupt jerkiness characterized every motion, and the 
failure of directive power was singularly illustrated 
at the piano, where the one incoordinate member con- 
trasted with the unusually skilful touch of {he other. 
As so often happens in the post-paralytic chorea of 



HYSTERICAL MOTOR ATAXIA. 45 

cerebral lesions, the palsy was inversely as the ataxic 
difficulty, and consisted rather in lack of persistent 
energy than in want of initiatory power. 

By slow degrees this ataxy of movement passed 
away, and what was most curious it lessened with the 
increase in want of power, while this also has in turn 
disappeared, leaving as yet some dysesthesia, but no 
notable want of strength. 

There yet remains to us hysteric paresis. Among 
the many disorders which hysteria affords, certain 
ones come clearly out at times from the tangle of 
named or nameless symptoms, and enable us to speak 
of them under some distinct name. It is a comfort, 
amidst so much that is confusing, to find these group- 
ings of symptoms, and, in diseases of vague bounda- 
ries like neurasthenia and hysteria, a good deal of this 
useful sort of secondary classification is possible. 

The history of hysteria is sometimes one of years, 
and in certain cases, either at the outset or after more 
or less of the strange drama of this disease has been 
played, the patient falls into a state of inertness of 
mind and body, which I am forced for lack of a better 
name to call hysteric paresis. 

You might, I presume, feel free to give to these 
cases another label than the one I have given. They 
are, however, over and above all else paresis — pure 
intense feebleness; but it is paresis in hysterical 
women, and if you forget this fact, when it exists, 
you may be sure that you Avill have but little success 
in the treatment. 

This disorder may be seen in union with other 
signs which are more or less clearly hysterical ; but 



46 DISEASES OF THE NERVOUS SYSTEM. 

sometimes we find it almost pure from these disguises, 
as in the case of Miss L., from New Jersey, now in 
the Infirmary. A person of languid nature, not strong 
in mind or body, she began some years ago to be emo- 
tional, to have loss of appetite, weakness, tender spine, 
vertex headaches, and abdominal tenderness and rare 
convulsions. By and by she took to bed, and with 
more and more complaint of her back, and soon of 
soreness everywhere, ate less and less, gave no care 
to her bowels, and at last became feeble, sallow, wasted 
to the limit of wasting, and content to lie still most 
of the time, using mind and body as little as she 
could. From this state I rescued her and made her 
well, and now she is here again far worse than ever, 
unable to lift a limb or to turn over. She is twenty - 
two years old, and has not menstruated in six months. 
She is five feet five inches, and may weigh about 
eighty -eight pounds. Her skin is rough, dry, un- 
pliant, yellowish, and seems to be firmly glued to the 
bones and muscles beneath it. Her morning tempe- 
rature does not exceed 97.5° F. ; her heart beats 90 to 
120, and is quick and feeble. The other organs seem 
healthy, and the secretions normal. She cries at 
times, but not much. Her face, marked with acne, is 
set, inert, wooden, as if she could not smile. The lids 
droop, the mouth hangs a little open, the voice is so 
feeble that it is hard to know what she says. The 
spine is very tender, and to touch it causes a gush of 
tears; but the left iliac fossa and the chest muscles 
are also tender, and compression of any of these 
hyperaesthetic spaces causes nausea and vertigo. Her 
dislike to make any effort was great, but it was clear 



HYSTERICAL MOTOR ATAXIA. 47 

that no motion was lost, although all were wonder- 
fully feeble. There was not during movement the 
jerky action of hystero-palsies, but an extreme and 
evident difficulty in motion, and a sudden failure to 
prolong it. 

I was very much struck in. this case with the ease 
with which these patients become feverish. The 
least over-exertion was competent to cause a distinct 
rise in temperature and pulse ; but, for some reason 
not yet clear to me, these changes required some 
hours to produce them. 

All the battery of toning influences was turned on 
this woman, and she is now gaining ground apace. 
She is fed often and in small amount, had for a time 
rectal feeding also — and the mechanical tonics, mas- 
sage, and electricity. As usual in all such cases, we 
wait until the flesh is coming back, the color bright- 
ens, and the muscles grow firmer under our mechani- 
cal stimulations before we call upon her to exert her- 
self. Then, in this order, with passive motion — 
motion aided by a nurse, motion resisted by a nurse, 
active motion, unhelped — we shall train her back to 
a state of health. We shall cure her surely, but 
Avhether or not she will remain well I cannot say. 
It will depend on what kind of influences surround 
her, on what she is when well. 

I have given here a short sketch of a state of 
paresis, in which with some anaemia or without a 
very marked condition of lack of blood all the func- 
tions are enfeebled, and this is most notable in those 
Avhich involve muscular exertion of any kind. If 
there be also any pain, such as that of spinal irritation 



48 DISEASES OF THE NERVOUS SYSTEM. 

made worse by motion, the patient is even more apt 
to be sluggish, and is not slow to avail herself of this 
and of every excuse to keep as quiet as possible. 
The real and singular want of power, as measured by 
the dynamometer, the difficulty in beginning as well 
as in continuing a motion, seems to set this apart 
from cases of mere neurasthenia, while the general 
wasting and appearance of mal-nutrition serve yet 
more deeply to mark the distinction. The disorder 
I have described so briefly is one of those which adds 
many recruits to that large class which some one has 
called "bed cases," and which are above all things 
distinguished by their desire to remain at rest. 

I shall elsewhere give in sufficient detail what I 
over and over allude to in these lectures — my views as 
to how best to treat those difficult combinations of 
hysteria with defective nutrition which are often too 
much for the best of us, and to those pages, and to what 
I have written previously in other places, I must now 
refer you. I have some belief in the occasional value 
of induction-currents in hystero-palsies,. but, as to the 
direct good to be had out of the drugs on which men 
once relied in the treatment of this disease, I have 
said nothing, because, except to condemn, I had 
nothing to say, and because I believe that the num- 
berless remedies for hysteria to be found in the books 
will be swept by another generation into the limbo 
provided for drugs with decayed reputations ; but in 
thus expressing myself I do not mean to say that no 
drugs have an indirect value. What you have to do 
is to rectify with care positive uterine troubles, to 
treat defects of nutrition, to relieve the anaemia so 



HYSTERICAL MOTOR ATAXIA. 49 

apt to exist in hysteria, to see that every function is 
well cared for, and last, not least, to learn what need 
there is to alter the moral surroundings of your 
patient, and then with kind and patient care, and an 
unbending will, to bring about the changes she may 
seem to require. 



50 DISEASES OF THE NERVOUS SYSTEM, 



LECTURE III. 

MIMICRY OF DISEASE. 

You will recall the fact that the case I show you 
to-day is one of three which have presented them- 
selves at this clinic within one week. Each of these 
by chance illustrates a different form of disorder, and 
each of the three is a distinct example of one of the 
various groups of causes which evolve a simulation 
of disease. The literature of this subject is widely 
scattered, and consists chiefly of isolated cases to be 
found in the journals. The best essays on the surgi- 
cal aspect of simulated disorders are the admirable 
lectures of Paget, Skey's little volume, and an able 
paper by Dr. Schaffer, of New York, on hysterical 
disease of joints. Except Eussell Eeynolds's paper on 
diseases due to fixed ideas or emotions, I know of no 
medical essay of much merit on this subject. It is 
to be desired that the whole subject should be handled 
afresh by some competent physician. It would be 
easy for me to make up for you an interesting history 
of these troubles from the experience of others, but 
I think that I shall be more pleasantly instructive if 
I deal only, or most largely, with cases coming within 
the range of my own knowledge, and especially if I 
make use of some of the curious self-analyses which 
patients who have recovered have placed at my dis- 



MIMICRY OF DISEASE. 51 

posal. Both for what they betray and what they con- 
ceal these histories are valuable, and especially so 
when they come from women of educated intelligence. 

The elements out of which these disorders arise are 
deeply human, and exist in all of us in varying amount, 
while many of the determining and conditioning fac- 
tors come from accidental, or, at least, external agen- 
cies. As a rule, the means at work to produce 
mimicked disease are in the books made to seem too 
simple. 

I have not time to do here as I might wish, and to 
go into the full psychology of this subject, and must 
content myself, therefore, with an outline which shall 
mark out for you the chief causes which supply the 
foundations for simulated diseases, and those which 
build on this, and those which strengthen and guard 
the morbid structure. 

First of all comes the hysterical state, fertile parent 
of evil. However produced, it is a fruitful source of 
mimicry of disease, in its every form, from the mild- 
est of dreamed pains up to the most complete and 
carefully devised frauds. Its sensitiveness and mo- 
bility, its timidity and emotionalness, its greed of 
attention, of sympathy, and of power in all shapes 
supply both motive and help, so that while we must 
be careful not to see mimicry in every hysteric symp- 
tom, we must, in people of this temperament, be more 
than usually watchful for this form of trouble, and at 
least reasonably suspicious of every peculiar or unu- 
sual phenomenon. 

TThat it is convenient to call the nervous tempera- 
ment, or that state which may be acquired, and which 



52 DISEASES OF THE NERVOUS SYSTEM. 

I like to describe as general nervousness, is a fertile 
field for simulated maladies, because in it, as in hys- 
teria, the qualities which we all possess are apt to take 
on a morbid development, and to get out of the limits 
of rational control. 

Of the individual share taken by each of these 
causes I shall by and by speak. Before, however, I 
pass on to lesser premises, I would like to digress in 
order to say a few words in explanation of what I 
mean by general nervousness. You will find this 
term used over and over in these lectures, and also in 
the annual statement of diseases treated at the In- 
firmary for diseases of the nervous system. I used 
to try to classify these cases under other heads, but 
came at last to see' that there is a state which is best 
labelled thus, and that after eliminating all the cases 
which can be otherwise classed, a small residuum is 
left to which no other name applies. Some of them 
are more or less neurasthenic people, easily tired in 
brain or body ; but others without this, or with this 
peculiarity but slightly developed, are merely tremu- 
lous nervous folks, easily agitated, over-sensitive, 
emotional, and timid. This state falls on man or 
woman or child, and is not hysteria. It is with some 
people a morbid birth-gift, with some an inheritance, 
and in its worst shapes it is made or acquired by mis- 
use of alcohol or tobacco, or tea or coffee. Naturally 
you may think that such a state must be slowly cre- 
ated, and usually it is ; but also it is true that a very 
permanent state of general nervousness may be 
evolved by the accident of a moment, when prece- 
dent conditions favor it. In a lecture on general 



MIMICRY OF DISEASE. 53 

nervousness in the male, I mentioned examples of 
this kind, and last week we saw at my clinic a case 
in which a moment of intense terror, owing to the 
fall of a house wall, caused in a healthy girl a state 
of general nervousness, alike serious and lastiner. 
However acquired, the condition I have outlined 
highly favors the mimicry of disease. 

Another good growing ground for simulation is in 
a mere lowering of the general tone of health from 
anaemia, or any cause whatsoever. You know that 
out of failing health comes, often enough, nervous- 
ness or hysteria, but even when these states do not 
arise, mere lowering of the standard helps, in many 
susceptible people, to awaken doubts, suspicions, and 
terrors, which need little hint or help from without to 
enable the victim to construct a morbid edifice of 
non-existent disease. 

If, then, you should ask me whether for the crea- 
tion of mimicked disorders we need the aid of low- 
ered health, of hysteria, or of general nervousness, I 
should answer that while such states are usually the 
responsible parents, a small proportion of examples 
arise in persons who being in absolute health owe 
the troubles in question to their possessing some 
natural or inherited combination of physical peculiari- 
ties, which becomes a competent mischief maker when 
aided by external accident. The people who, from 
any cause, simulate disease are, I think, apt to be natu- 
rally distinguished by certain peculiarities. They are 
generally over-sensitive, pain hurts them more than 
others, and is a more important matter in life. Per- 
haps they really feel pain more, and, at all events, 



54 DISEASES OF THE NERVOUS SYSTEM. 

they complain of it more. As a rule, they are timid, 
fearful, and watchful, nursing for evil, any chance 
word incautiously dropped, and, therefore, prone to 
dwell on physicians' opinions, to deduce exaggerated 
possibilities of trouble, and in obedience to the least 
prediction of ill to consent or hasten to take extreme 
precautions. 

Then, again, you are aware that every one has some 
capacitjr for mentally influencing or disturbing func- 
tions of the body which usually are not under the 
control of volition. A few well people have this in 
a marked manner, and in some hysteric or nervous 
states this power becomes enormously increased and 
widened in range. I do not mean that these people ac- 
quire the power to will intestinal trouble, for instance, 
but that they certainly may gain ability to somehow 
disturb the bowel functions by thinking of them. 
There are many stories in regard to this ; but let the 
average man endeavor by any mental process to cause 
diarrhoea, and he will, I think, find it no easy task. 
It seems incredible that a woman can learn to vomit 
at will; but this is common; and, also, happily she 
can be taught to suppress this vomiting by volitional 
effort when the will is aided by a potent motive. 

Books like Dr. Tuke's are full of stories illustrative 
of such facts, and I myself have seen a large number. 
It is clear, then, that we can sometimes acquire such 
control over functions supposed to be outside of 
volitional rule, and that this is made easier in certain 
temperaments and in states of hysteria, feebleness, or 
nervousness. 

The disturbances thus brought about lie usually in 



MIMICRY OF DISEASE. 55 

the heart or vessels, or in the gastrointestinal track, 
and are caused or aided by expectant attention or 
dread, or by morbid watch fulness with a knowledge 
of symptoms. 

It has been said by Hunter, as quoted by Tuke, 
that, if a number of men surrounding a table on 
which they have placed each a hand will fix their 
attention on the member, some of them at least will 
soon feel in the part a peculiar sensation. I have 
tried this in vain, and I have also tried without re- 
sult to cause my heart to beat quicker by merely 
attending to its action, yet I am myself of a rather 
nervous temperament. It is curious to find John 
Hunter avowing the ease with which he could in 
this manner create symptoms, and then to find Sir 
James Paget declaring himself utterly unable to pro- 
duce mimicry of disease by any amount of attentive 
effort. The difference among healthy men in this 
respect must, however, be immense. Of this I had 
once a curious illustration. When a very young 
man, five of us made a series of what are called by 
the homceopathists provings of certain medicines, 
each man being ignorant of the drug taken ; three of 
the five had a great variety of symptoms, but the 
other two had none. It is well to add that the 
symptoms corresponded neither among the observers 
nor to those set down in the homoeopathic manuals. 
My friend, Professor Tyson, will recall an amusing 
example of the effects of expectation in a patient of 
ours. The first day he saw her, in order to use 
electricity, she chanced to have at the time, as she 
always had under excitement, a loose stool. This 



5Q DISEASES OF THE NERVOUS SYSTEM. 

took place also at his next visit ; and thereafter he 
never made a call at a set time without causing sharp 
purgation. When he came nnlooked for, then the 
whole trouble left her. It brought to my mind the 
case of a well-known English physiologist, who hap- 
pened to have diarrhoea when about to give his first 
lecture. The embarrassment and annoyance were 
great, and so impressed him that for a year he never 
lectured without having just beforehand a loose stool. 
The sufferer chanced to relate these facts to a well- 
known physician, then a very young man; being 
himself also a biologist, he unluckily felt interest 
enough in this matter to recall it when soon after 
about to appear for the first time before an audience. 
The excitement attendant on a novel situation, with 
a knowledge of how it had affected another, caused it 
to have a like effect on him, and for a long time he 
was always thus annoyed when about to lecture. 

I have given these as illustrations of increase of 
action under mental disturbances and expectation or 
dread. They could readily be multiplied. In the 
two cases named, anxiety caused the repetition of a 
flow which was at first accidental, or, at all events, 
not-born of emotion alone. In like fashion arise and 
continue certain of the forms of cardiac and vasal 
nervous disturbances. First there is some sadden and 
unusual influence disturbing the circulation, then, 
upon occurrence of lesser but like causes, a similar 
trouble arises, until a morbid habit is fully formed. 

There exists in all of us, feebler in age and more 
potent in childhood, a tendency to automatic and 
unconscious imitation which is the parent of a good 



MIMICRY OF DISEASE. 67 

deal of the mimicry of disease. It may exist in sim- 
ple forms, or be accented by love, anxiety, fear, or 
even disgust. 

I have said it was potent in the young, and it is in 
them responsible for a good many of the peculiarities 
and resemblances usually set down to inheritance ; 
but it is also to be seen at times in their elders. 
Some months ago I was showing to a physician a 
very singular case of unilateral grimace. As I 
turned from my patient, I noticed that the doctor 
was repeating with his own features the morbid 
action before him. I said, "Do you know that you 
were imitating this lad's grimace?" "I know now," 
he said, "but I must have clone it without conscious 
imitation." Perhaps no better or more illustrative 
example of the natural tendency could be given. 
This was pure automatic imitation. 

The tendency to cough, when forced for a long 
time to listen to a cough, is an instance where ten- 
dency to imitation is made powerful by sympathy or 
affection. It may account for some at least of the 
false whooping- coughs we meet with. 

A far more amusing example is one which I have 
seen several times, but which seems to have escaped 
mention in print. It is the occurrence of vomiting in 
the husband of a pregnant woman. The story of one 
of these unlucky sympathizers is worth telling : — 

He was rather noted as an unfaithful mate and a 
man of altogether loose ways. After five years of 
marriage, his wife becoming pregnant — an event much 
desired — he seemed to reform, and was very much in 
her society. Her vomiting, which was extremely 



58 DISEASES OF THE NERVOUS SYSTEM. 

severe, at last affected him, every day or two, to his 
utter disgust. Her second pregnancy gave rise to a 
return of his malady. I believe that she ceased to 
be sick with her third child — certainly with her 
fourth — but, so soon as on each occasion he became 
aware of her state, his vomiting came on, and lasted 
for a month or two ; indeed, I think, in one case much 
longer. 

The character of his disorder at length became 
known to his friends, and he was so mercilessly 
chaffed that it was at last almost dangerous to men- 
tion the matter. I have seen other cases — his was 
the worst — but I was told of one in New York last 
week, and the victim was a physician. 

I may have overlooked something in my search 
through the books for mention of these curious facts. 
Prof. Groodell reminds me of what Francis Bacon 
says (Cent. x. Para. 986): "There is an opinion 
abroad — whether idle or no I cannot say — that loving 
and kind husbands have a sense of their wives breed- 
ing child, by some accident in their own bodies." 
Did he mean vomiting, or some more mysterious 
diagnostic warning? In the Lancet there is brief 
mention incidentally of a husband as having been 
sick at stomach during his wife's pregnancy. 

There could be no better examples than these 
somewhat ludicrous instances of the influence of au- 
tomatic imitative tendencies. In the case just men- 
tioned, the habit became so strong that emesis was 
re-excited by a mere knowledge of the fact that there 
existed in the woman the state out of which pre- 
viously had grown the original trouble. 



MIMICRY OF DISEASE. 59 

Instances of graver disease evoked in like fashion 
have been given by Reynolds and Anstie, and always 
it is found that fear, or the sight or the remembrance 
of suffering in others, has been an efficient means of 
aiding the imitative tendency. In this manner trou- 
blesome paresis, simulative of palsy seen in a relative, 
has been produced. The condition thus acquired is 
not a true palsy, and does not give us the full roll of 
symptoms seen in the real case; but it is something 
more than a mere voluntary imitation, because there 
is often a distinct incapacity for movement. The dif- 
ficulty as to the amount of true pain felt in such of 
these cases as mimic that symptom, I shall more than 
once have occasion to speak of; and it follows us 
everywhere in our efforts to fairly appreciate the ex- 
tent of nerve irritation. It must bear to true pain 
perhaps some such mysterious relation as the paresis 
of these cases bears to true paralysis. 

I saw last winter a young lady of highly nervous 
and timorous organization, who was long under my 
care, and at length fullv recovered. While in bed an 
indiscreet attendant tolcl her of the horrible agony 
she had witnessed in a case of facial neuralgia, which 
began daily about 11 A. M. A day or two later my 
patient began to have pain in the same locality and 
at the same hour every morning. She was one of 
those women in whom you could cause pain any- 
where by pressure on the spine, and a few suggestive 
and directing remarks ; and no more was needed than 
the frequent mention of the torment of another, and 
the remembrance that she herself had already had 
what was called ovarian neuralgia. For some days 



60 DISEASES OF THE NERVOUS SYSTEM. 

she really seemed to have an intense facial pain. It 
wore away after I ceased to pay any attention to it. 

There is a state of mind and body, not rare in well- 
developed hysteria, in which there exists a so mon- 
strous development of this strange power to create 
disorder by thinking of it, that even a slight hint, as 
it were, will suffice to evoke a novel symptom. In 
this disease, indeed, we find women, and men too, 
passing into a mental state in which they are really 
much like people in dreams. Their power to reason 
on the phenomena of the senses leaves them, and what 
they conceive to be the case takes the place of that 
which is. These are they who are hurt by light, or 
believe they are ; who cannot bear noise, or think 
they cannot; who feel vibrations as pain; who live 
muffled lives in dark rooms, and believe they cannot 
walk, or even lift a hand, or move the head. Such 
cases are looked upon as simulations of disease by 
some writers, and are, I am sure, prone to pass into 
that evil stage of hysteria ; but there are others I also 
know who live lives of odd inhibition — slaves to the 
tyrant ideas which they themselves create. 

This, of course, is to be met with, to some extent, 
in all grave hysteric cases ; but it is also, as I have 
said, the ruling feature of a few. If you cause such 
hysteric women as these to believe that you can cure 
them, you enlist on your side their own troops, for as 
you can create symptoms, so can you also create ab- 
sence of symptoms. There is in all this something 
like the so-called magnetizing of which we used to 
hear and see so much. Under a fixed belief people 
were made unable to move, or could not close the 



MIMICRY OF DISEASE. 61 

eyes, or could not open them, or were made to seem 
to have a pain by touching a point on the body. The 
patients I speak of are all very subject to like delu- 
sions. You put a finger firmly on the spine, and ask 
if the patient have now a pain in the left breast? 
She says no. You persist. At last she says, "Yes — 
Oh, it hurts me!" Now, is this pure sham, or is it 
not ? Does the presence of the set belief create pain ? 
Is it like the pain of dreams, which seems real enough 
while we are in the state of dreaming? I have 
thought over all this a great deal. When we put a 
finger on the eye unopened for days, and say " Now 
you can open it," and this is done ; or when we arrest 
motion by an order, we see a plain physical result 
which must have behind it a ganglionic change out of 
which it grows ; and so it seems to me that, looking 
at the pain evoked by ideas or beliefs in the light 
we get from the motor phenomena, so evolved, we are 
hardly wise to stamp these pains as non-existent. 

At the same time that I put forward this doubt as 
to the justice of the common view, I am far from 
thinking that the hysteric girl of the class I am now 
discussing suffers as sharply as she seems to do ; the 
emotions are no more under control than in a dream, 
and no pains are little, no burdens light. 

I have now in my care Miss C. from Milwaukee. 
When I first saw her she was in bed, which she quit 
but rarely and with difficulty. The room was kept 
dark, and she wore blue glasses over the closed eyes, 
and outside of all a bandage. She used cotton in her 
ears, and her nurse and parents crept about in list 
slippers. She had in all ten pillows, large and small, 
6 



62 DISEASES OF THE NERVOUS SYSTEM. 

as supports around her, and was, as a young hysteri- 
cal girl once told me, " crowded with symptoms." 

The character of this girl had always been that of a 
person thoughtful of and for herself, and not free from 
esteem for her own mental powers, so that she had 
been able and also very willing by degrees to rule 
a meek household with that reckless despotism the 
throne of which is very often the couch of an invalid. 

This case seemed to me one in which set beliefs, 
easily gotten and well nursed, had attained a power 
which gave rise to pain and over-sensitiveness and 
more or less inhibited movement. I began -to deal 
with it by learning all I could from the girl herself 
to add to what I already knew of her mind, her morals, 
her habits, tastes, friends, education, and home life. 
Then the talk was left to settle on her eyes, and at 
last on the uses of light, and the fact that its excess 
hurts even the healthy, but does not injure them. 
When at last she grew interested, and with herself 
for a text that was easy, I said, that perhaps a woman 
of strong character might learn to bear the light after 
long disuse of her eyes ; that such a one could not get 
well readily in the dark, and that although the light 
would pain her, it most surely could not cause dis- 
ease. I then left her, with the idea that she could in 
a few days conquer her rebel eyes, and that it was 
absurd for a woman of intellect to let one organ dis- 
order the whole body. The next day I found her 
with open eyes and sunlight in the room. One by one 
the ideas on which the case was built were thus art- 
fully removed, and she is now after but a few days of 
treatment far on the road to health. 



MIMICRY OF DISEASE. 63 

These victories are less easy with older women ; 
but even then the mode of dealing with them is as 
much a question of the basis of character as of any- 
thing else. Sometimes we only need to dispel one 
symptom to overcome all ; sometimes the return to 
health and healthy ideas exacts a long and tiresome 
struggle. Sometimes it is safe to assure the patient 
at the outset that she has but to believe and exert 
herself in order to walk. 

In this innrmar}^, I saw a few years ago, an abrupt 
success obtained in this latter way in a woman, fifteen 
years in bed, who was made able to walk well in three 
weeks, and I could easily add, were it needed, the 
details of many other and less striking cases. 

I had meant to say something here of that form of 
hysteria in which the patient deliberately acts a part 
and with more or less cunning deceives those about 
her. I have seen a goodly number of these cases, but 
among them I have found quite rare the attempt to 
simulate palsy. It is easy enough to learn when a 
woman is pretending to pass calculi or vomit snake- 
bones, but to know if her loss of power be real, or if 
she be suffering from an inhibitory idea or belief is 
more difficult. I may say, however, that purely simu- 
lated palsies in hysterical girls, lack the qualities of 
hystero-palsies, are too complete, and show no loss of 
feeling. The best cases I can recall were in very 
young girls, and were present with much mental dis- 
turbance, and after a long role of hysteric symptoms 
had been played with success. 

One of the cases I lately showed you was a curious 
and most instructive illustration of imitation where 



64 DISEASES OP THE NERVOUS SYSTEM. 

distress and terror at witnessing disease in a sister 
were the efficient factors. 

Mary C, aged nine, had frequent, sudden, and 
severe attacks of epilepsy. After they had lasted 
two years, the mother brought her to my clinic, and 
with her a lad aged eleven. He was a puny, fee- 
ble, pallid boy, easily alarmed, and so nervous that 
he could hardly answer my questions. It seemed 
that nearly six months before I saw him, he ran a 
nail into his foot, and, about the time the wound 
healed, had something like an hysterical attack, which 
seems to have impressed him with the idea that he 
was afflicted in the same manner as his sister. Soon 
after this he had what the mother called a spasm, 
whenever the girl was attacked, and still later when 
he heard she had a convulsion, or at times without 
this suggestive cause. His attacks began with tremor. 
He was said then to become insensible and to shake 
all over violently. There was no tongue biting, and 
no coma following the attack, and no facial spasm. 
After becoming satisfied of the psychical origin of his 
disorder, I ordered him a cold douche whenever at- 
tacked, and directed that he should have the hot iron 
applied to his neck if the attacks did not cease in a 
month. At the same time the sister's fits were con- 
trolled by bromides, so that he ceased to have before 
him the constant incitement to attacks. Without 
further treatment, the boy's fits, if I may so call them, 
promptly disappeared, not all at once, but by degrees, 
and he is now well. That in this case the fits of /the 
boy were imitative is clear enough — that withont the 
model before him they would not have arisen is plain. 



MIMICRY OF DISEASE. 65 

We need not ask a cause for simpler forms of imi- 
tation, as seen in normal functional acts, as when the 
micturition of one in a herd of cattle awakens the 
idea among the rest and leads all of them to follow 
the example. The imitative tendency is a useful part 
of our developing powers, but here in cases like that 
of this boy, where there are other children, he alone 
imitates. Does the terror he only as a timid nervous 
lad feels, intensify his imitative faculty, and what 
motive is there for yielding to such a tendency ? It 
may be that there is a certain pleasure in giving way 
to instinctive imitative propensities, and moreover we 
must all have observed how some sick children enjoy 
the important role of being ill, of being coddled and 
attended to, and this is especially noticeable in large 
families, or in asylums, where usually no one child 
receives in health undue attention. Such aids as 
these there are, no doubt, to cases of mimicry, while 
sometimes the patient's surroundings are to be blamed, 
as fastening the disorder or even as giving such infor- 
mation about symptoms as is consciously or not ap- 
plied to the perfecting of them, the actor receiving as 
it were, from a too sympathetic audience, hints which 
enable him the better to sustain his part. 

Some of you saw but lately the case which sug- 
gests these remarks. Here, again, the actor was a lad. 
The following details of his case I owe to his physician, 
Dr. Benjamin Smith, of Falsington, in this State: — 

0. F., ast. 9, had at school a slight chill, and in the 
evening thereafter headache and fever ; he was well 
next day, but was said to have had headache the day 

6* 



66 DISEASES OF THE NERVOUS SYSTEM. 

following. At this date the doctor found him suffering 
from great tenderness at several points of the spinal 
column. He could not recall having hurt his back, 
but a few days later declared that he then remem- 
bered having fallen so as to strike the back, and that 
the pain was severe ; also, that, on the same day, he 
had fallen so as to hurt his head. Both falls were 
said to have taken place on December 25th. 

As soon as the tender spine and headache were 
known to exist, the lad was kept at home and anx- 
iously cared for, while the pain in the head increased 
and extended at last to the spine. At this date a 
remarkable dilatation of the pupils was observed, 
and, the pains increasing, he would lie in bed and rub 
his head for relief, or have it rubbed. Meanwhile 
his pulse was not above 80, and did not rise with the 
presumed increase of pain ; nor did he lose appetite. 

About the fourteenth day the headache was said 
to be at its worst, pains arose all over the body, and 
the muscles of the neck began to be complained of 
as sore and stiff, while nausea and pretty violent 
vomiting added to the alarm which his case excited, 
being set down, despite Dr. Smith's opinion, as an 
attack of cerebro-spinal meningitis. At this time, 
after the vomiting ceased, there was a sudden cessa- 
tion of all the symptoms; but in a few days more his 
troubles returned, and with dreadful complaint of 
head- and back-aches, with universal soreness and 
utter inability to walk, he was at last brought to me 
for an opinion and for treatment. His case had then 
lasted five weeks, and was supposed by some phy- 



MIMICRY OF DISEASE. 67 

sicians and by his relatives to be of a dangerous 
gravity. 

When I saw this lad he was lying in bed, some- 
what flushed, but not in a bad condition ; his pulse was 
85 ; his breathing 20 ; his temperature normal. His 
eyes were bright, and I was struck, as Dr. Smith had 
been, by the widely drlated pupil. He was constantly 
declaring that his head hurt him, and it was, as I 
observed, very notably retracted, the muscles of the 
neck being stiff and tender. Any effort to flex the 
head gave rise to tears, remonstrances, and urgent 
cries of pain. The scalp was everywhere tender and 
the whole of the erector spinas masses were also sore, 
so that the least tap or touch upon them caused him 
to cry. His legs were gathered up close to his body, 
and, besides some loudly expressed annoyance when 
exposed to a bright light, he complained bitterly of 
the vibrations caused by carriages passing or of the 
steps of his nurses when they moved across the room. 

If, however, he were interested in anything, I 
found that I could flex the head or touch the spine 
without causing pain until his attention was recalled 
to the act. This — with the absence of fever, the 
calm pulse, the fair appetite, and a certain watchful 
and furtive expression — led me to believe that he 
was more or less consciously mimicking disease. As 
soon as I felt secure in my opinion, I lifted the lad 
out of bed, and, with severity, ordered him to stand 
up ; he hesitated a moment, and then dropped the 
flexed limbs under him, lifted his head at a second 
order, and, as I released him, walked to his bed — a 
feat which he had been supposed to be utterly unable 



68 DISEASES OF THE NERVOUS SYSTEM. 

to do. After this there was no trouble; he was kept 
out of bed, and, with a rough rubbing daily and a 
little urging, was able to play in the garden in three 
days and to go home in a week. His pains, stiff 
neck, and tender spine were never heard of after the 
first day in the hospital. I was careful to have him 
kept on a farm away from his home for some months. 
There has been no relapse. 

This case excited great attention, and was the centre 
of the too affectionate regards of many relatives. The 
lad became early aware that he was believed to be in 
grave danger. His head and spinal pains were attri- 
buted to meningitis and the symptoms discussed in 
his hearing. Only thus can we account for his curious 
condition, when, in the face of opposition founded on 
his presumably serious state, Dr. Smith brought him 
to me. 

I saw some years ago a like case in the person of a 
young woman who had nursed two cases of cerebro- 
spinal meningitis. Her imitation was admirable and 
for some days took in both her own physician and 
myself. 

Careful use of the thermometer and a rigorous 
study of symptoms can alone enable us to avoid such 
traps as these. They illustrate what may occur in 
nervous people, under the influence of depressing 
agencies and when surrounded by too great sympathy 
and by all the information needed to enable them to 
act a part. 

The lessons which such cases teach us are obvious 
enough. The need for care in discussing symptoms 
before nervous women or children, the necessity of 



MIMICRY OF DISEASE. 69 

early apprehension of the true state of things in 
simulated disease, and the wisdom of acting decisively 
when once we are sure of our ground, are all of them 
points on which it is hardly needful that I should 
dwell. 

On my return from Europe in October, 1880, I was 
asked by Dr. Stryker to see in consultation a number 
of cases at the Church Home for Children, and, 
as these present the most amazing illustration of 
mimicked disease I have ever seen, I shall describe 
them as being the best possible illustration of nearly 
every point on which I have dwelt. The home is a 
handsome, wholesome asylum for children, and is 
situated a few miles from Philadelphia. It contained 
about 95 girls and but 6 boys. Both the sick and 
well when I saw them were amply-nourished, and 
healthy-looking ; nor was it possible to find in their 
home or in their habits any influences which could be 
credited with giving birth to neurotic tendencies. The 
diet w r as good, the hours regular, the play and out- 
door life sufficient ; neither was there in the education 
given, nor in the religious training, anything with 
which it was possible to find fault from a medical 
point of view. 

Dr. Stryker gives me in substance the following 
account: Margaret Trimble, aet. 12, a rosy and sturdy 
brunette, in admirable health, is one of a neurotic 
breed, there being in the immediate family two cases 
of infantile palsy. On September -1th, in the dormi- 
tory, when in bed at night, she began to have without 
known cause, unless it might have been a trifling indi- 
gestion, slight convulsive twitches of the arms and 



TO DISEASES OF THE NERVOUS SYSTEM. 

legs, with a little numbness of the extremities. This 
was a matter of a half hour, and she got up well next 
day. There were no further attacks until the 11th, 
and thenceforwards they returned daily. At first she 
was well in the intervals, and slept and went about 
like the other girls. Her respiration during the 
attacks was harsh and noisy, and she made at each 
inspiration a loud crowing noise, much like the breath- 
ing in croup. The attacks, rare at first, soon became 
frequent, and lasted from fifteen minutes to three 
hours; attention from others inevitably brought them 
on, even when she was seated and laughing or chat- 
ting with her companions. She would then slip down 
to the floor, and hands, feet, and body would be seized 
with uncontrollable convulsive motions, so that it was 
impossible to keep upon her person clothes or bed 
covering. During an attack she lay on her back, or 
rolled from side to side, while both arms and legs 
thrashed the floor with quick and hard blows. The 
body was lifted from moment to moment, and thrown 
down again with violence, in a fashion strange to see. 
Meanwhile, her face was contorted with swiftly chang- 
ing grimaces, and the tongue thrust out and drawn in, 
while her head was thumping hard on the floor. 
Sleep was apt to follow a fit, and there was at times, 
and later in the case, a good deal of choreoid difficulty 
in moving, or in handling objects; at times the crow- 
ing existed alone, and at times the legs became feeble, 
and she stumbled and fell about. 

This child was sent to the Hospital of the Univer- 
sity of Pennsylvania, where she remained two months, 
under the care of mv friend, Professor Horatio Wood. 



MIMICRY OF DISEASE. 71 

Dr. Musser, the Registrar, sends me his notes, from 
which I add the following particulars: — ■ 

The muscles of the face, neck, eye, and tongue were 
at this time unaffected by the spasms. "While seated 
she swayed backwards and forwards in clonic spasms. 
When lying down, her spasms were much as I have 
described them. There was lack of coordination in 
all arm and hand movements, but no anesthesia any- 
where. There was tonic spasm of the adductors of the 
thighs, and in a slight degree of the flexors of the fore- 
arms. All movement ceased in sleep. There was no 
lesion of the eye ground. The urine was normal. 
There was a slight systolic roughening at the apex of 
the heart. The usual remedies for chorea having failed, 
the actual cautery was twice used on the spine, but 
with no better fortune. Etherization on a full stom- 
ach caused vomiting for twenty-four hours, and a 
permanent relief of all the symptoms. Under careful 
and systematic training of the muscles, with much 
urging, and a good deal of scolding, she made finally 
a complete recovery. 

This girl's case was seen by many of her comrades, 
and not only excited their amusement and curiosity, 
but led some of them to imitate her "bark," so that 
they were reproved by the matron for their tricks. 

On September 8th, Dr. Stryker being in the home, 
Kate Nichols, a wholesome looking girl of 10, was 
brought to him in the nursery, in what seemed at 
first to be a sharp attack of false croup. She was 
breathing hard, gasping, crowing, speechless, and 
wildly clutching at her throat. Her possible relation 
to the first case was not then understood, and she was 



72 DISEASES OF THE NERVOUS SYSTEM. 

treated as if for croup. The trouble persisted all day, 
and was noted as made worse by noise, or any ex- 
citement, and to be by and by associated with slight 
convulsive jerkings of the limbs. Meanwhile, the 
pulse was rapid, but there was no fever. The follow- 
ing night all of these troubles passed away in a sound 
sleep, from which she awakened crowing and barking; 
and after a day of increasing nervous agitation, ex- 
ploded in a convulsion, identical in character with that 
of case ISo. 1. The attacks thereafter increased in 
violence, but all of her functions were well performed. 
She ate, drank, and passed urine and feces as usual, 
and when free from convulsions was merry and pleas- 
ant, until the approach of a nurse with medicine, or 
the visit of a manager to the Infirmary, started her 
off anew. From the outset she began to lose power 
in the limbs. When held up she would start fairly, 
but instantly the legs became convulsed, the feet 
tripped one over the other, and she fell in a fit on the 
floor. 

The girl was also treated at the University much 
as the last case ; the cautery was of little use, but the 
effect produced by ether on her comrade had a de- 
cidedty good moral influence, and seemed to have a 
good deal to do with her recovery. 

Case 3. — On September 9th, Sallie Speer was seized 
w^ith the same form of respiratory spasm, but with 
the crowing noise there was a continuous chattering 
of the teeth, like that of a bad ague chill. On the 
10th the usual convulsions came on, she having 
ample preparation from seeing those of the other 
children. In a few days all of her symptoms passed 



MIMICRY OF DISEASE. 73 

awaj, and she returned to the school-room, for a week, 
when the same disorders reappeared, and she was once 
more placed in the nursery. 

Case 4. — Florence Pierce, aet. 12, had about the 
11th like attacks, but, besides the usual convulsions, 
she had remarkable mydriasis in the intervals. While 
yet able to walk she had singular attacks of festina- 
tion, and if going towards her bed would run furiously 
and be thrown headlong across it, and on to the floor 
beyond. Generally she crawled about on her hands 
and knees, with her head swaying about as if it was 
held up with difficulty. 

Case 5. — Miriam Drinkhouse, aet. 11, was depressed 
on account of having been placed in a lower class than 
her comrades, owing to her inability to keep up with 
them in their studies. Next day she was unable to 
stand, and her first fit followed on October 13th. 

Case 6.— Fannie Clark, aet. 12, was taken ill with 
respiratory spasms, and the same convulsions about 
October 13th. She had also remarkable coldness of 
feet and hands, which was not observed in the others. 

Florence Mack, aet. 8, Sarah Nolen, aet. 12, Florence 
Mulligan, aet. 10, Bella Burk, aet, 11, Mary Mitchell, 
aet. 12, were all taken about the 12th to the loth of 
October. Their symptoms were much the same as 
those above described. There were also a number 
of other cases, some slight and some severe. Owing 
to want of space all the first cases were placed in the 
two adjoining rooms of the infirmary. Here they 
were seen by one another, and also more or less by 
such girls as were engaged in the housework. Other 
cases were soon added, and at last there were at 
7 



74 DISEASES OF THE NERVOUS SYSTEM. 

least ten cases in the apartments mentioned. The 
results of this companionship may be easily imag- 
ined; at first the convulsions were irregular as to 
time, but after awhile they took place only in the 
evening, and later still in the morning and the even- 
ing; although at any time a visit such as mine, or that 
of Dr. Stn r ker, or of a lady manager was sufficient 
to start the attacks. Then one girl would begin to 
bark or twitch, then a second and a third, until on 
bed or floor, or seated, ten or twelve children were 
wheezing, barking, grunting, crowing, or in violent 
convulsions ; while the bewildered nurses ran from 
one to another, presenting a scene quite astonishing 
to witness. 

During a few days there were many interesting 
variations in this singular maladv. On one occasion, 
all of the children in the sick ward got out of bed at 
night, and took to walking about on their hands and 
knees ; at other times some of them described in 
soliloquy dreams, one saw black men, another, whose 
mother had been recently pregnant, described herself 
as having had a child, and mentioned the luxuries she 
considered desirable for a person so situated. More 
commonly the girls were scared, or said they were, by 
wild beasts, and one child would adopt the vision 
which another related within her hearing. After con- 
sultation all of the cases were scattered about among 
different hospitals, 1 where, as a rule, they made prompt 
recoveries, under somewhat various treatments. The 
cases lasted from one month to three. 

1 The Jefferson College, the Presbyterian, and the Episcopal 
Hospitals. I am indebted to Dr. Starr for full notes of several of 
the cases. 



MIMICRY OF DISEASE. 75 



LECTURE IV. 

MIMICRY OF DISEASE. 

The cases with which I have illustrated this sub- 
ject of mimicry of disease have been, so far, some- 
what simple and uncomplicated; nor could they have 
readily or long deceived any watchful physician who 
had had any experience of neurotic maladies. There 
are, however, more complicated cases to be met with, 
and some of these are remote from those so far de- 
scribed, in that the symptoms were not imitated from 
models ready at hand, or wholly learned from gabbling 
nurses or relatives. 

They exhibit also the curious progress from simu- 
lation, not consciously imitative to conscious unre- 
sisted simulation, and at last dissimulation. I shall 
relate here two admirable instances of these inter- 
esting combinations of mimicry passing into well- 
sustained fraud. 

A good many years ago I saw, one evening, a girl, 
aged 13 years, who had never had any of the maladies 
of childhood excepting measles. When her new trou- 
bles began she was not as yet menstruating, nor did 
she show any notable signs of womanly development. 

In January, 1866, when skating, her right instep 
became chafed severely, and for this she was kept at 
rest for two or three weeks, but received very little 



76 DISEASES OF THE NERVOUS SYSTEM. 

care from her mother, and, in fact, needed but little. 
One day an attack of indigestion ended in vomiting, 
which was very violent, and which brought about her 
all the sympathy her elder relatives could give. From 
this time her appetite failed, and the vomiting re- 
curred at intervals. Long after, she told me that she 
could have vomited less, but that everybody was kind 
when she was so sick. Here, at least, was a distinct 
failure to resist, and probably a desire to aid, in pro- 
ducing sickness of stomach. The vomiting grew more 
frequent in the spring, and after a fortnight of fever, 
which she is said to have had in June, 1866, all food 
was thrown up, and the bowels were opened only 
once in ten days, or even less often. These conditions 
persisted through 1866, with little change, the child 
rejecting everything, and growing at last sallow, and 
desperately wasted. The skin became sensitive to 
touch, so that no water could be used for fear of caus- 
ing convulsions, and most of the time she was shaken 
by violent hiccough. 

The vomiting, at first accidental, was thus at last 
aided and cherished for a purpose, until, as often hap- 
pens, the morbid act became habitual and despotic. 
But in a nervous system such as this child's no such 
habit could persist without giving rise to other symp- 
toms as grave, while these in turn would be nursed 
and developed to win and keep up the sympathy, 
attention, and importance, which are among the un- 
natural moral appetites, of a nature once started upon 
this disastrous road so strewn with multiple dis- 
orders. When such persons get well, their lips are 
so surely sealed by shame and self-disgust, as to make 



MIMICRY OF DISEASE. 77 

it difficult to verify by frank confession the suspicions 
which arose in the minds of bystanders, or to trace 
the fatal steps by which the victim descends, from the 
state in which she welcomes a symptom, to the degra- 
dation of creating symptoms. My patient, when first 
seen by me, had been abandoned, as in a dying state, 
by two homoeopathic physicians, who had left for her 
use a prescription of rather ample doses of morphia. 
The picture which this child presented when first 
I saw her was not readily to be forgotten. She was 
lying on her back, staring upwards, with glassy eyes 
set deep in dark rings, which faded into a sallow lea- 
thery skin, drawn tense over projecting bones. Her 
mouth was wide open, the jaw dropped, and the whole 
cavity literally lined with thrash (muguet). 1 The 
skin of the body was dry, and splotched with islets of 
dusky red, and the bedclothes were kept off' of the 
sensitive surface by a shelter of half-hoops. As I stood 
and looked at this singular spectacle, apparently that of 
a dying child, she groaned at brief intervals, and also 
coughed a good deal, at such times expressing pain in 
her face, but usually lying quite still, with a look of 
merely the most profound melancholy. A careful 
study enabled me to find no organic disease. Her 
urine was so scanty that she often passed but two 
ounces a day ; but this was not albuminous ; the belly 
was very tender to touch, although, if I distracted her 
attention, neither touch nor pressure caused any sign 
of pain; attention was needful to enable her to feel 
these pains, but as it may be said that attention is for 

1 The coating of oidium albicans was the most remarkable I have 
ever seen. 

7* 



78 DISEASES OF THE NERVOUS SYSTEM. 

all pain a reinforcing element, too much stress must 
not be laid on this point. I noticed, however, that 
this wretched, wilted, starved creature followed my 
motions with attentive eyes, although she never turned 
her head. 

I asked for milk, and put within her lips a table- 
spoonful, for which she closed her mouth ; a moment 
passed, and with a gulp she threw it up. I repeated 
the dose, keeping a finger on the larynx. Again she 
threw up, or seemed to; for, as the larynx did not 
make the usual upward movement which accompanies 
the act of deglutition, it was clear that she had not 
swallowed at all. I watched this neat little fraud 
several times. Usually she swallowed a part of each 
mouthful, and, holding the rest in her mouth, sud- 
denly cast it out with a very fair imitation of the 
convulsive act of emesis. When quite sure of having 
correctly observed her, I abruptly charged her with 
the deceit. At first she denied in a faint voice, 
and saying she couldn't help it, began to cry. A 
little sternness enabled me to get down her a full 
glass of milk. I then cleared the room of all her 
friends, threw away the hoops, and sat down by her 
side. She Avas evidently conquered and alarmed, 
which I did not wish her to be. I therefore took 
her hand quietly, and told her that she could get 
well ; that milk was needful ; that, if thrown up, it 
would be given again, and that I meant to feed her 
whether she liked it or not. 

The after-care, which owed its success largely to 
the care of Dr. Wm. W. Keen, was arduous enough. 
The belly — and, indeed, ihe whole skin — was rubbed 



MIMICRY OF DISEASE. 79 

twice a day with sweet oil; milk was given freely 
ami often, and the bowels rid of their packed con- 
tents by the use of frequent enemata. I found the 
spine exquisitely tender, but, as is often the case, this 
was much helped by ice-bags (dry cold). Meanwhile 
the thrush faded under the use of washes of sulphite 
of soda. The patient's head was elevated a little day 
by day, and the diet was increased and varied. The 
bowels proved so obstinate that nothing but croton 
oil moved them, and the trouble of swallowing per- 
sisted for some time, although lessened whenever her 
attention could be called away from the act of deglu- 
tition. Incessant attention to the muscular apparatus 
of the throat had made the use of these parts diffi- 
cult, and swallowing having ceased to be automatic, 
was re-embarrassed by every new concentration upon 
it of an act of will. When she received milk in her 
mouth it always rested there for some time ; if, how- 
ever, the head was thrown back, and at the same time 
the larynx pushed up by a hand, this sort of hint 
usually proved successful, and the movement of de- 
glutition was completed. By degrees this trouble 
passed away, and she gained in strength so as to sit 
up, and after awhile to stand. 

The use of induction currents to the disused mus- 
cles w^as a further help, and, with the gain in power, 
came back easier movements of bowels and bladder, 
and a more wholesome moral tone. Within six weeks 
the girl was able to call at my house, and she is now, 
I believe, the healthy mother of a family. 

I could never extract from this child, when well, 
anything beyond the statement that she "just could 



80 DISEASES OF THE NERVOUS SYSTEM. 

not help it;" and if I pressed her further, she said 
she was sorry, and took refuge in tears. 

About two years ago I saw, with Dr. Finn, a case 
quite as remarkable. The girl, aged thirteen years, 
living in Ohio, after an attack of ague, began to limp 
a little one day, and said she had a pain in the right 
knee. A physician examined it, and told her parents 
quite trnly that there was no cause for alarm, ad- 
vising at the same time exercise, and a let-alone 
treatment. This would have answered well, and 
have saved much trouble, had not some one per- 
suaded her mother to ask advice of the travelling- 
agent of a surgical institute, who diagnosed hip-joint 
disease, put on a temporary splint, and arranged to 
cure the child at the institute. From this time, when 
the little public opinion about the girl pronounced 
for a grave malady, she grew speedily worse, and 
under the influence of the discussions as to the hip- 
joint disease and its symptoms, she began to act out 
as fully as possible the pathological drama so foolishly 
taught her. The pain increased, and the leg con- 
tracted at the knee and hip. At the institute things 
grew worse, and very soon there was double hip dis- 
ease, and local applications, and splints, many and 
wonderful. But when one of these curious cases is 
well engaged in this career of simulation, there comes 
a time when, either because the first trouble no longer 
excites sympathy, or for more complex reasons, these 
forms of disease become progressive and invasive. 
In our little patient, the contractions of the thigh re- 
maining, the arms, especially the left, became flexed, 
the feet being in full extension. At this time hyster- 



MIMICRY OF DISEASE. 81 

ical spasms came on ; the eyelids elosed, and remained 
shut ; and, most strange of all, she was unable to 
eat before 9 o'clock P. M. In this state the child 
was first seen by Dr. Finn, who removed her to quiet 
lodgings, where soon afterwards I saw her, and heard 
this exasperating history of folly and quackery. As 
I first saw her, she la}' on the bed, her back to the 
light — a queer little shrivelled creature, tawny of 
tint, and the skin covered with bran-like scales, wash- 
ing being a rare ceremony. Legs and arms were 
drawn up so as almost to hide the thin, ancient-look- 
ing and cunning little visage, which seemed so blind 
with its closed but quivering lids, and yet so unnatu- 
rally astute in its intentness of attention when her 
own case was mentioned or discussed. 

Her right hip was red and swollen, and the thumbs 
of both hands had been so long and tightly contracted 
as to have caused the palms to ulcerate, while the 
whole skin was sensitive to such a degree that the 
bedclothes were not allowed to touch her, and she 
uttered a muffled cry of dismay and seeming terror 
at every approach ; her voice was reduced to a faint 
whisper, and she was said to be totally blind. 

The treatment in this case was of easy enough 
application in a child. A single nurse was left in 
charge. The legs were violently straightened and 
their owner invited to set them in order, so as to 
avoid in future this abrupt and painful treatment. 
"We were told as usual that she never could eat until 
nine P. M., and wonder was expressed that, having 
her eyes shut, she was able to know what o'clock it 
was. The clock on the mantel was an obvious aid, 



82 DISEASES OF THE NERVOUS SYSTEM. 

and at all events, when set forward two hours, the 
nine o'clock meal was asked for at seven. The gain 
in this case was steady and easy enough. I lost sight 
of the child after she left us to return home, but at 
the time of her departure she was nearly well, and, 
I learn, has entirely recovered. 

I have often thought that, if I could induce older 
patients who had been affected more or less like these 
children to relate to me their histories with sufficient 
frankness, I should obtain a larger insight into the 
motives which prompt them to cultivate or to create 
symptoms. As interesting additions to this rare 
branch of medical autobiography the three letters 
which I subjoin must suffice : — ■ 

II The period of my life about which you ask me, 
I can only look back upon with a sort of disgust 
which makes it unpleasant for me to speak about ; it 
is only the hope that some one else may be helped 
by it which makes me willing to speak of it at all. I 
was brought up by an invalid aunt, and I often think 
of what you once said to me, that the women who 
indulge their own nervous systems are those who 
most indulge children. My aunt taught me very 
early to notice and dwell upon any little symptom I 
happened to have, and, when I was fourteen, I un- 
luckily hurt my knee. For this I was kept in bed 
two weeks, and, when I wanted to get up, I was told 
to keep quiet. Under this enforced rest my appetite 
failed, and I began to have nausea. My first vomit- 
ing: created a sensation in the household, which I 
think, as I recall it, I enjoyed as making me impor- 
tant. Yery soon I got to vomiting every day ; there 



MIMICRY OF DISEASE. 83 

was none of the nausea which I had at first, and 
which I have since been familiar with as a part of 
sea-sickness. It gave me no annoyance to cast up 
my food, and was indeed rather a relief. From this 
time I was surrounded with sympathy and doctors. 
A few months later my aunt died and I was left in 
charge of an uncle and aunt, and became one of a 
large circle of children, among whom I got very little 
of the care which had before this encompassed me. 
I remember well that I resented the change, and, 
finding that if I took little food I excited alarm. I 
began to yield to the tendency to excite distress and 
anxiety by taking little or no food at times. I sup- 
pose this abstinence gave rise to the nervousness, 
and finally to the spasms which came on at this time, 
at least I can give no further explanation ; I only 
know that every new symptom caused new anxiety, 
and that I somehow liked it all. After a while a new 
doctor was called in, and under his rule, which was 
very stern, I got better, and was able to leave home 
and go to the seashore, where, under new influences 
and interests, I lost all of my symptoms except the 
vomiting, which seemed to me uncontrollable. I lost 
this only by resolute efforts; in fact, by efforts so 
desperate that often, when food rose in my mouth, I 
swallowed it again. I do not think I should ever 
have so tried if I had not overheard a person in w r hom 
I had a great interest express himself as having heard 
with disgust of my habit. Then, as you know, I 
learned from you that the habit could be broken ; I 
succeeded, as you know, and am married and have a 
little girl, and I can promise you that she at least 



84 DISEASES OF THE NERVOUS SYSTEM. 

will never be allowed to go through what I have 
done." 

I presume that this partial self-analysis is as near 
to a full and truthful statement of the motives which 
urge to mimetic fraud as we are likely to get. I 
have been told by one woman that she was as irre- 
sponsible as one in a dream ; while more usually you 
are told simply "I do not know why I did it ; I could 
not have meant to deceive any one." My next extract 
from these confessions is in some sense honest enough, 
and, as I said before, is curious, both as to what it 
reveals and what it hides. The writer is long since 
dead, and I am therefore at liberty to use her letter 
with such precautions as make identification im- 
possible. 

I had seen my patient in the morning and received 
this letter in the evening. For several weeks she had 
been under my care with these conditions, a good rosy 
color, fair weight, and regular functions ; but at times 
enormous losses of urine and intense spinal irritability, 
which forbade her to stand or to walk a step. For her 
food she ate a chop at breakfast, and no other food 
the rest of the day. You must not understand me to 
say that I accepted all these statements, but merely as 
briefly sketching what seemed to be her state. This 
very pretty invalid was a charming and witty, and 
most accomplished person. After her husband's 
death, she had taken to her couch, and, despite aches 
and ailments, was .in her becoming sick outfit the cen- 
tre of an attractive circle, which gladly gathered about 
the couch, on which she was carried from room to 
room. I hardly know under what circumstances she 



MIMICRY OF DISEASE. 85 

developed the full range of her powers. The irri- 
table spine came first, and as one doctor after another 
was consulted other symptoms were added to her 
repertory. 

She had been some little while under my care 
when I saw two things which confirmed m} r well- 
grounded suspicions as to the nature of her case; she 
slept alone, disliking the constant presence of a nurse ; 
but she rarely failed to ring for her attendant twice 
every night. 

The last mornino- I saw her I had occasion to look 

o 

at her feet, and noticed that her soles were dotted 
with black marks; coupling this with the fact that 
she had complained of her wood fire as having smoked, 
I concluded that she had been afoot in the night, and 
that the dark marks came from " blacks" on the floor, 
the result of a defective fire draught. A moment later, 
observing some crumbs on her bolster, I asked her to 
sit up that I might examine her spine. As she rose, I 
threw aside her pillow, and saw under it two oranges, 
several slices of bread, and a banana. To my amaze- 
ment she said coolly, "Well, now I am caught: I 
thought you would do it soon or late." My rather 
sharp remonstrances seemed only to amuse her, and 
that evening I received the letter, a part of which I 
print. 

"Before this reaches you I shall have made arrange- 
ments to leave. The game I have played on you I 
have played on others, and in my restricted life I 
have found it very amusing. You must not blame 
my maid, as I paid the woman who cleaned the room 
to bring me food. I found that doctors got tired of 
8 



00 DISEASES OF THE NERVOUS SYSTEM. 

my sore back, and that they ceased to feel interest in 
me, a thing I never did like, so I began to complain 
of queer symptoms, and as this often aroused new 
interest, I went on experimenting until I hit on the 
starvatiou idea, which has done very well ; of course 

1 got up at nights and walked a good deal too, but 
how you knew it I would like to know. As to the 
urine, I used to fill up the vessel with water. I hope 
you will not tell my doctor at home, you would take 
away a good deal that is pleasant, and spoil an inter- 
esting case too." 

These are the only cases of this form of moral 
obliquity, in which I have ever been able to get a 
free confession. They expose, I fancy, to some ex- 
tent, the motives which underlie the duplicity of 
such Avomen. 

The last of these statements is more recent, and I 
have permission to print it. It is in some ways more 
valuable than the others ; the belief this woman at 
last reached as to the want of foundation for her pre- 
sumed physical disabilities, and her continued con- 
viction that the pains were as distinct as any pain, 
must, I think, be received with respect. I am sure 
that she has done her best to analyze her symptoms 
truthfully. 

She came to me on a couch, or litter, from a "West- 
ern State, a girl of 19, not wasted, and of good tints. 
She was said to be unable to walk, motion hurt her ; 
and her eyes were carefully guarded from light by a 
double bandage. She was kindly but firmly treated, 
and was able in a few days to bear sunlight, and to 
go downstairs. When once she had been made sure 



MIMICRY OF DISEASE. 87 

that all this could be clone without death, I allowed 
her to go forward more slowly, with such help from 
tonics, good diet, etc., as I could give. She very often 
talked to me about the cause for her disorder, and out 
of my inquiries and interest in her case came the self- 
analysis I append. It needs no commentary. 

"I suppose, in all cases of nervous affections, one's 
natural temperament and constitution play an impor- 
tant part, and, doubtless, with me, a temperament 
rather emotional, sensitive, and occasionally morbid, 
had something to do with making possible the state 
I was in when I went to see Dr. Mitchell, in Decem- 
ber, 1879. 

"The immediate cause for the headaches, which 
began a year before that time and never left me after 
it. seemed to be a few weeks of mental and social 
strain. I had for two years before that time suffered 
from a weak back, had felt constantly tired, spent 
much of my time on the bed, and taken but little 
exercise. But in the fall of 1878 I felt much better 
and undertook study and class recitation, and became 
much interested in some evening literary and social 
clubs. For a few weeks I went every day to the 
utmost limit of my strength, and was then suddenly 
prostrated with severe headache and excessive weari- 
ness. 

"I, of course, tried quiet and rest immediately, and 
after a while grew better, but had a return of head- 
ache and weariness whenever I tried exerting myself 
much again. There is no question that what I lacked 
then was courage. If some one could have told me 
that there w r as nothing of consequence the matter, I 
am sure I should have overcome the difficulty and 



88 DISEASES OF THE NERVOUS SYSTEM. 

very soon have gained endurance by exertion ; but, 
instead, I became afraid to do things for fear of bring- 
ing suffering, and, as month after month passed, I 
could do less and less. I cannot now understand why 
I could not have seen, why I could not realize that 
the less I did the less I could do ; but I was blind, 
and so was every one else. I thought it was some 
strange, mysterious disease that was taking away my 
strength. By summer, a few minutes' conversation 
or the walk of a block would make the pain in my 
head agonizing, and every sound became unendurable. 
My eyes, too, shared in my good-for-nothing state. 

"In the fall, the pain went into my back and limbs 
and sent me to bed with the strange infatuation that 
I could not move without injury, as 1 certainly could 
not without pain. I had lain in one position with 
closed eyes for eight weeks, before going to Dr. 
Mitchell, in a state of supposed helplessness. One 
thing I want to say in extenuation of myself, and 
that is that the pain was real, not fancied. Whatever 
its cause or however easily it might have been 
averted, it was genuine suffering at the time. I was 
scarcely ever hysterical either in the usual sense of 
the term, for, at least, I realized the necessity of self- 
control. 

"In looking back over that year with the light of 
the present, I can only say that I believe there was 
nothing really the matter with me, only it seemed as 
if there was, and, because of those sensations, I carried 
on a sort of starvation process, physical and mental. 
Why that process should have brought me into such 
a condition, I must leave with some one wiser than I 
to unriddle." 



SPASMODIC AFFECTIONS IN WOMEN. 89 



LECTURE V. 

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN 
WOMEN. 

You will find, if you come to "have much experi- 
ence in the cases of hysterical women, that in some 
instances the disorder arises in general convulsions 
following upon a state of acquired nervous instability, 
and then runs on into a great variety of symptoms — 
palsies, hyperesthesias, and anaesthesias, and contrac- 
tions — to end, at last, in years of bed-ridden invalid- 
ism, or, much more rarely, in spinal sclerosis. A 
single case will thus give you, in disorderly and un- 
expected succession, every scene of what I have ven- 
tured elsewhere to call the drama of hysteria. 

At the risk of repeating an old story, I have sought, 
in one of these lessons, to relate some of these histo- 
ries, chiefly that I might illustrate afresh the termi- 
nation in sclerosis, and partly to show what might be 
done to rescue certain of what seem to be the most 
hopeless of these exasperating cases. 

Apart from these, however, we see two forms of 
hysterical disorder, in which the primarv signs are 
either slight and aborted, or remain so inconspicuous 
as to give but little aid in the early diagnosis. One 
of these is marked by mental derangements, and is 
usually treated as simply a causeless insanity until 



90 DISEASES OF THE NERVOUS SYSTEM. 

some outbreak of the commoner forms of hysteric 
signs reveals the true condition. I mention it here 
only to complete my rather rude and partial classifi- 
cation. The other is characterized by the extraordi- 
nary variety and strangeness of the convulsive disor- 
ders, which, for years, and from time to time, afflict 
the patient ; all other symptoms being present rarely, 
or in feebly-represented forms. I propose to relate 
and discuss for you some of the most unusual of these 
cases. 

In 1871 I was consulted by an intelligent unmar- 
ried lady, Miss L. P., ast. 26, from Mississippi, for a 
condition of system which was probably due to cer- 
tain emotional disturbances following a violent onset 
of cholera morbus. The attack was repeated a few 
days later. The day after, she had intense burning 
pain between the shoulders and down the whole length 
of the spine. This symptom lasted long, and with it, 
for a month, during which she kept her bed, there 
were brief periods of febrile activity. She is said to 
have had no severe headache, and no uterine or uri- 
nary symptoms. On first rising she found that her 
legs were feeble, and this paresis was best marked on 
the left side. 

When first seen by me these symptoms remained 
unchanged. The weakness of the left side was com- 
plained of both in the arm and leg, and as affecting the 
eye. She needed a supporting arm when walking, but 
did as well in the darkness as in the light, and stood 
fairly well with shut eyes. The left sole was slightly 
less sensitive than the right. Above this there was 
no dysesthesia. There was also no analgesia, and 



SPASMODIC AFFECTIONS IN WOMEN. 91 

heat and cold were well distinguished. There was, at 
times, a sense of extreme weight on the chest. The 
burning pain in the spine was unequally distributed. 
It was worse at the 5th and 6th dorsal vertebrae, and 
was increased at night and by fatigue. The temporary 
application of ice made it worse, and this increased suf- 
ering was felt for some time afterwards. Elsewhere she 
had no fixed suffering, but complained of darting neu- 
ralgic pains almost at any point of the body. There 
was no womb trouble of moment. On the left side there 
was a large area of variable iliac tenderness, not great, 
and sometimes absent. It was less on deep pressure 
than on slight touch. The eye-grounds were normal, 
but she was said to have at times double vision, if 
very tired. 

This case, as I recall it, puzzled me greatly, and 
was finally treated as of organic cerebro-spinal 
origin ; and this idea was strengthened by the fact 
that at times there was distinct rigidness of the erec- 
tor spinoe muscles. She came under my care first in 
the autumn of 1872, and gradually improved. The 
back was several times cauterized early in January, 

1873, and great gain followed. Somewhat later a slight 
and singular tottering of gait was seen ; but, on the 
whole, the progress was good and steady ; so that, by 
the end of January, 1874, she could walk with ease a 
quarter of a mile on level ground. In February, 

1874, Miss P. made the mistake of leaving home, 
and subjecting herself to what was, for her, excessive 
fatigue and much social excitement. Then, as always 
since, fatigue brought on more or less nervousness, 
and the singular forms of spasms which have proved 



92 DISEASES OF THE NERVOUS SYSTEM. 

so enduring an annoyance. At the close of a day of 
unusual fatigue, on rising from her chair to cross the 
room, she suddenly staggered back, and then rotated 
violently several times. These fits returned over and 
over, and resulted within a week in fresh dorsal pain, 
extreme lassitude, and a curious inability to keep her 
balance. Meanwhile, the rotations were usually, but 
not always, to the left. The loss of equilibrium was 
great. On rising she would pitch forward, and then 
sideways, and then turn swiftly. The pitching was 
really convulsive, and not due to lack of balancing 
power, and there was no subjective sense of giddiness. 
She came to see me soon after, and was much worse for 
the journey. During ten days of quiet here the rotatory 
spasms gave place to violent and nearly constant spas- 
modic jerking of the head backwards or forwards, to 
right or to left. As this also departed she had a new 
onset of what she called " twists," and thenceforward 
turned only to the left. These spasms were amazing 
things to see — suddenlv, while crossing the room, she 
would rotate furiously to the left — about three to six 
times. The turn was very rapid, and seemed to begin 
with the spine. Then the head followed, and, as she said, 
it seemed hard for the legs to keep up with the back. 
At other times an irresistible power seemed to drag 
her up on to her tiptoes, where she would remain a 
moment, as it were, fixed. At this time she could 
walk, or even run backwards, but a forward move- 
ment was beset with difficulties. She would be, as it 
were, hurled forward, and then rotate, or the effort to 
move in a forward direction would end in a rapid 
retrogressive stagger, followed by rotation to left. 



SPASMODIC AFFECTIONS IN WOMEN. 93 

There was no vertigo execpt as a result of the spin- 
ning. In June she went home, and from this period 
she had a succession of slow gains with sudden re- 
lapses. If leading a very quiet life, she sometimes 
passed six months without spasms. Worry, fatigue, 
excitement were all sure to bring them on. At times 
there was no warning, but usually pain in the feebler 
leg, nervousness and irritability were premonitory of 
an attack. Then she would of a sudden find one leg- 
oddly twisted around the other, or wonld be drawn 
up on to her toes, or forced to walk on her heels, or 
would pitch hither and thither, not from weakness, 
but from alternating unilateral spasms. At these times 
her will seemed to be absolutely suspended. "It is," 
she says, "as if some other will power had me in 
possession. I struo-o-le against it in vain." 1 

x CO o 

The first point to notiee in this case is its generic 
relation to the class of functional spasms of Duchenne ; 
those in which spastic movements are associated with 
or follow some form of normal muscular action. 
Such spasms do not arise during repose, and in this 
sense chorea is at first, and in some cases throughout, 
as I have elsewhere observed, a form of functional 
spasm. 2 Perhaps I shall, in a measure, clear your 
minds as to the nature of what I mean by functional 
spasms if I recall to you the influence of strychnia in 
large doses — such as you have seen given here many 
times. You will remember that in certain spinal 

1 For analogous cases see Russell Reynolds's System of Medicine, 
art. Chorea. 

2 Am. Journ. Med. Sci., October, 1876. 



94 DISEASES OF THE NERVOUS SYSTEM. 

maladies, such as those of syphilitic birth, it is my 
habit first to give iodides in heavy doses, and then to 
suspend these for a time, and to give strychnia up to 
the limit of physiological endurance, that is to say, 
until I cause an approach to spasms. When, for ex- 
ample, you give hypodermically the one- fifth to the 
one-eighth of a grain daily — the patient will have 
little or no annoyance if you are careful to insist 
that he remain at absolute rest in bed for two hours 
after each injection. If there be any tendency to 
spastic twitchings of the muscles, the will is compe- 
tent to control them, unless, and this is the point I 
would make, the patient attempts to exercise. Should 
he do this, the effort results at once in irregular move- 
ments of an incoordinate character, and in slight or 
more grave spasms of the muscles employed. While 
at rest there is no obvious trouble, but voluntary 
movement occasions spasms, which are the offspring 
of the poison. They are, in a word, functional 
spasms, and would not be seen at all, with limited use 
of strychnia, were it not for the efforts at voluntary 
action. 

The second consideration to which it is worth while 
to call attention was the great variety of the forms 
assumed by Miss L. P.'s attacks, and the temporary 
limitation of the disorder to partial groups of muscles. 
This alone would, I think, entitle us to suspect hys- 
teria as a cause ; and, when we learn that no attacks 
ever took place in the street, and that pleasant sur- 
roundings lessened the likelihood of the occurrence 
of the spasms, while all depressing and enfeebling 
agencies were apt to bring them on, no further 



SPASMODIC AFFECTIONS IN WOMEN. 95 

doubt should exist as to the parentage of the disorder. 
Muscular action perfect in health loses in force and in 
sureness, and in steadiness, as any one falls away from 
the highest standard of physical condition, and when 
there is in the ganglia some cause tending towards 
irregularity in any shape, it also is apt to rise into 
gravity just in proportion to the failure in physical 
status. Add to this emotional disturbances, which in 
certain natures are prone to express themselves in 
some form of irregular muscular acts, and we have 
all the needed factors for producing such convulsions 
in persons at all capable of evolving them. 

I consider that the treatment, which I need not here 
consider, utterly failed. I never succeeded in raising 
my patient's health to such a level as to put her above 
the possibility of these curious attacks. I, perhaps, 
ought rather to say that I never could keep her at 
that level. The least blow to health was with her 
a knock down, and recovery was slow. Practically 
speaking, the woman who habitually has hysterical 
spasms has something wrong with her general health. 
She is anaemic, or has lost general tone, and cannot 
get up, so to speak, or there is that remarkable state 
of easy tire Avhich is called nervous exhaustion, but 
which were often better called nervous exhaustibility, 
and which is, perhaps, due to some form of defective 
nutrition of the nerve centres. Always there is some 
such cause behind the spasms. If we can relieve it 
we cure the convulsions, or rather make the soil fatal 
to their growth. I do not think this is always pos- 
sible. There are some anaemias which resist all treat- 



96 DISEASES OP THE NERVOUS SYSTEM. 

ment. There are some mysterious forms of nutritive 
failure which are never made well. 

I have seen recently a case which somewhat re- 
sembles Miss L. P.'s. Miss C, a native of Maryland, 
jet. 21, was sent, when 17 years old, to a school in 
which boys and girls were educated together. Just 
before leaving home she had two slight attacks of 
"stiffness" when rising from the sitting posture. 
While at school she never menstruated, although 
previously regular. Next came a light attack of 
diphtheria, and still her general health seems not to 
have been obviously damaged ; but the "contractions" 
grew more frequent until at last one day, in class, she 
was unable to speak, owing to trismus which came 
on as she rose to recite. She went home after this 
event, and in a few weeks her menstrual flow re- 
turned; nevertheless the spasms continued, and this 
despite a gradual rise in health, and a nature free 
from melancholy, and prone to seek and find healthy 
enjoyment in outdoor life. A further gain followed 
a residence of some weeks in the West, but still the 
attacks continued ; nor did it seem that almost per- 
fect health secured immunity. 

At present, in 1880, this young woman looks in ad- 
mirable condition ; nor is there, on careful study of her 
case, any evidence of organic disease or functional dis- 
order. While seated she never has any symptom of 
spasm ; but many times in each day, when rising from 
a seated or recumbent posture, she is seized with at- 
tacks which I have now seen her exhibit many times. 

On rising she is seized with spasms of the legs, 
neck, face, and arms and hands. These vary end- 



SPASMODIC AFFECTIONS IN WOMEN. 9T 

lessly, and are not often exactly alike in any two 
attacks. Usually the phenomena are these, and in 
this order : — 

Just as she begins to move, after rising from a 
chair, she has — 

1. A stiffening of the muscles of the legs and 
chiefly of those of the thighs. This causes a certain 
constraint in her first steps, but does not prevent 
them. 

Having moved a few steps she has — 

2. A consentaneous spasm of the neck (twist to left 
and downward pull), of the bodj^ also to left, of the 
lower part of the face, either to left or right, or stiff- 
ness from bilateral spasm of face. The left arm is 
sometimes in violent flexion from fingers to shoul- 
der, or the arm is extended and the hand flexed. 
There is the same variety as to the movements of the 
right arm. When I last saw a fit the right arm and 
hand were thrown out in rigid extension, the left 
being as perfectly in flexion. 

3. No matter what posture was assumed, she was, 
so to speak, fixed in it for perhaps ten to fifteen sec- 
onds. The spasm came on, and rather slowly culmi- 
nated in some one odd posture, and there and then 
the woman became, as it were, a statue for the 
moments that followed. 

4. These spasms were painless, and disappeared in 
an instant. 

5. They caused no confusion, or vertigo, or any 
other ill feeling, nor any sleepiness. She went on at 
once to do whatever she had meant, such as to walk 
or to dance. 



98 DISEASES OF THE NERVOUS SYSTEM. 

At times the attacks are frequent, at others rare, 
and absence from home and change of scene and cli- 
mate seem to lessen the number of fits. 

6. These spasms are often but not always preceded 
by a condition Avhich is sometimes chronic, at others 
comes only as an immediate warning of attack; at 
all events its presence is a sure sign that the attacks 
will come on readily and be more than commonly 
hard to prevent. This precedent state consists in a 
slight general tingling which varies in amount, and 
is apt to be accompanied by a sense of stiffness in 
the muscles of the legs. These are rather evidences 
of a chronic and slight condition of spasm than of any- 
thing which it is worth while to call an aura. 

If, on rising, she stands still a moment and prepares 
herself to walk by some indescribable mental act, which 
is not a mere resolve because here the will is quite 
powerless, she can prevent an attack. To rise quickly 
and walk at once, or to turn abruptly just after begin- 
ning to walk are apt to cause fits. 

The relationship of such attacks of functional 
spasm as these is as near to chorea as to epilepsy, for 
the state of which she speaks as favoring and preceding 
a tit cannot for reasons already given be looked upon 
as an aura, and we know of no epilepsies in which the 
functional and orderly act of a muscle or muscles 
gives rise in some way to the irregular and disorderly 
discharge of nerve force which constitutes a spasm. 
But in grave chorea, this is precisely what does occur, 
the forms of spasm having of course in that disorder, 
as in functional spasms, differentiating peculiarities. 
I gave this woman bromide of lithium chiefly to see 



SPASMODIC AFFECTIONS IN WOMEN. 99 

if the bromides would control or lessen the fits. The 
attacks were not lessened by this agent. 

After this failure I was at a loss how to deal with 
the case. There are spasms which are so nearly a part 
of the normal muscle acts or so tied up with them as 
to be as hard to change by medicine as the orderly 
sequence of any common muscular action, nor is the 
task of reform more easy when years of repetition 
have made deep the easy ruts of habit. I could only 
insist that she must live so careful a life as never to 
rise without being on guard. Then also, since violent 
exertion distinctly lessened her tendency to spasms, I 
advised an abundance of exercise. The results of this 
advice were good, and the case rapidly prospered 
when she took to hard housework, which happened to 
interest her very greatly. 

The next case which I desire to add to this group 
of spasmodic disorders, is, like the last two, remark- 
able for the great variety of distorting forms assumed 
in turn. Some of you may recall the patient, a poor 
unmarried seamstress, aged forty- three, tall, thin, and 
with a face constantly and deeply flushed ; a pulse of 
90 to 100, and, so far as I could discover, no organic 
disease. When nearing the age of forty she began to 
have retarded menstrual flow, but neither then nor 
when seen by me a year later, was there any uterine 
trouble. In June, 1878, after some family annoyances, 
she had a severe rigor, ending in trismus which came 
on abruptly, and repeated itself thereafter with like 
suddenness, and at inconvenient seasons, usually while 
she was eating. In August it was replaced by dys- 
phagia. She acquired, as a consequence of this 



100 DISEASES OF THE NERVOUS SYSTEM. 

condition, a deadly fear of the abortive efforts to 
swallow, and would chew for many minutes before 
making an attempt at deglutition. In the autumn 
this too passed away, and in October she first con- 
sulted me at ray clinic for a " lump" on the chest. I 
was about to refer her to one of our surgeons when 
her remark that it went and came interested me, and 
I carefully examined it. . To my surprise the growth 
was in or on the left great pectoral above the breast. 
It was an oval flattened swelling with quite abrupt 
edges. If I carried the arm out so as to make the 
muscle tense, in a few minutes the tumor disappeared 
gradually, and I perceived that it was a phantom 
tumor with which I had to deal. I was familiar 
enough with these as seen in or on the belly, but I 
now saw only my second case of this phenomenon in 
any other muscular mass. The "tumor" was hard 
and dense, and the temperature over it was a half 
degree above that of the neighboring parts. Hard 
rubbing gradually dispersed it, but it formed again in 
a few hours, and I may add was always tender. 

I next found to my great interest that all of the 
pectoral on this side was in a state of curious irrita- 
bility, and this you will recognize as only an increase 
of a normal quality. When, for example, I strike a 
healthy muscle with a finger tip, or better, a pointed 
caoutchouc percussion-hammer, such as that which we 
use to test tendon reflexes — two facts are observable. 
First, the whole length of the muscular fibre struck 
contracts, or a large part of the whole length. Then, 
as it relaxes, a little hard prominence forms in the 
muscle at the part struck, and remains for a few sec- 



SPASMODIC AFFECTIONS IN WOMEN. 101 

onds until it gradually disappears. 1 In this woman's 
case, the secondary local contraction was larger than is 
usual, and lasted for at least a half hour or more. A 
few weeks later, she came to the hospital to stay, and 
now the pectoral tumor had gone, and the belly pre- 
sented the usual appearance of a phantom tumor. All 
of its muscles were violently contracted, so as to look 
like a rounded growth. It was painfully tender and the 
percussion note was dull. It, however, presented one 
peculiarity I had never seen in any other such. case. 
Several times a day the whole contraction passed away, 
but the least handling of the belly brought it all back, or 
this took place without any interference. The woman 
was during all this time in a state of amazing nervous- 
ness, and was seized with universal tremor whenever 
any one came near to her bed. Her pulse rose at times 
to 130, and the temperature fluctuated daily and 
irregularly from 97° F. to 105° F. We got her well 
enough to walk about and to leave the hospital, but 
the abdominal contraction still existed or did so after a 
year had passed away. 

I have seen a similar false tumor in the calf of a 
highly hysterical lady. It was relieved in a week or 
two by the daily use of massage. 

I shall complete this group of cases by a very singu- 
lar one, which I saw last year. M. B., female, set. 59, 
a worn-out school teacher, always feeble and lacking- 
blood, but otherwise well, had a slight sprain of the 

1 I described these phenomena many years ago in the Trans, of 
the Phila. Acad. Nat. Sci., not then being aware that Weber had 
called attention to them. They are best seen in the pectorals of 
thin people. 

9* 



102 DISEASES OF THE NERVOUS SYSTEM. 

knee, which forced her to remain at rest. Very soon 
she perceived a rhythmical spasm of the middle of the 
muscular masses of the calf of the left leg. The mus- 
cle gathered into a hard painful swelling about five 
inches below the popliteal space. The contraction, 
which was two by three and one-half inches in size, was 
sudden and horribly painful, and the region attacked 
was always sore, but was most so during the spasm. 
This lasted a few seconds, but the space affected was 
at all times hot and a little hard. The spasms were 
singularly regular, about twenty-five to thirty a 
minute, but there were often long periods of one to 
five hours during which no spasm existed. She had 
been treated in various ways without relief, but I was 
finally enabled to help her by rest in bed, the use of 
a splint, and careful feeding and iron, but the local 
trouble was not entirely cured until I had used seve- 
ral injections of atropine, which were thrown into the 
muscle, a plan which was, I think, first employed by 
Drs. Morehouse, Keen, and myself in the Hospital for 
Nervous Diseases durino- our civil war. 

To complete the group of unusual forms of spasm 
in women, I shall only add a case or two of hysterical 
athetosis. Since Dr. Hammond first described this 
interesting member of the family of choreoid spasms, 
I have seen two cases in which the athetoic spasms 
were simulated in hysteric women. One of these I 
saw but once, as it did not return to my clinic ; the 
other was a private patient, and was long under ob- 
servation. 

L. C, ast. 25, from Canada, a stout ruddy unmarried 
woman, was probably overworked at puberty in ac- 



SPASMODIC AFFECTIONS IN WOMEN. 103 

quiring accomplishments which she can no longer use. 
At 14 she had diphtheria, but no sequent palsy. The 
hysterical aspects of her case are represented by ten- 
dency to tears, by rare hystero-epilepsy, by fits of hyste- 
ric coma, by great nervousness, distress at loud sounds 
and bright lights, and by general abdominal tenderness. 
Over and above these it is to be remarked that she 
has a certain general feebleness, not at all suggested by 
her look of health, nor is she ever very steady in her 
motions, and is liable to a fine tremor, which subsides 
only after she has been for some time at perfect rest. 
Also there is a slight but distinct and very slow os- 
cillation of her eyes, so that this group of symptoms 
suggests sclerosis. Otherwise she is well, and it may 
suffice to say so without going into negative details as 
to sensation, motion, reflexes, and the functions in 
general. 

Possibly this is an hysterical woman with an organic 
malady, but to which cause shall we refer the athetoic 
spasms, which I shall now describe? When for relief 
the hands lie closely locked on her lap, save for a fine 
tremor little movement is to be seen, but when re- 
leased, and especially during excitement or attention 
to them, both hands, the left being the worse, exhibit 
the most singular motions. The fingers extended, or 
in extension and flexed on the palm, move to and fro, 
coming together or separating, or crossing the line of 
the thumb. These motions are slow, and of a per- 
fectly disorderly character, but they never cease 
except in sleep and during efforts at any manual 
work, when they are always replaced by the slight 
tremulousness alreadv alluded to. In Dr. Ham- 



104 DISEASES OF THE NERVOUS SYSTEM. 

mond's cases, at least in the one given as a type, the 
movements continued during sleep, and also they 
were powerful, and there was some pain in the limbs 
concerned, but none of this applied to my patient. 
The motions could be easily controlled by another's 
hand, the resistance being but slight, while also there 
was no pain. When, however, my patient grew ex- 
cited or emotional, the movements became rapid, and 
during her menstrual periods, which were natural, this 
was also the case. There was no spasm in the feet. The 
history of these movements is that they arose out of 
a succession of hystero-epileptic fits, with intervals of 
stupor, or of stupor with rigidity. At the close of 
these attacks, although she was in other respects well, 
the fingers were noticed to be strangely affected, and 
the disorder thus begun grew slowly worse. 

The only question is as to the origin of these spasms. 
Is it an athetosis proper, or an hysterical imitation of 
athetosis, or merely athetosis grown, as one might 
say, on an hysterical soil, and modified by its place of 
growth ? Despite the fact that the athetosis arose 
directly out of hysterical disorder, I incline to the 
latter view, especially as in many particulars the case 
otherwise conforms sufficiently to Dr. Hammond's 
admirable account. I ought to add, however, that in 
cases more clearly and purely hysterical, athetoic 
movements are sometimes met with. 

In my second case, that of an unmarried woman. 
Miss J., set. 40, there were slight mental disorder, 
sensory delusions, left hemianesthesia, an hysterical 
temperament, and slight ovarian tenderness (left). 
Eapid relief of the mental trouble was obtained under 



SPASMODIC AFFECTIONS IN WOMEN. 105 

treatment, with slow improvement and final cure of 
the anaesthesia, large gain in flesh and blood, and 
entire recovery from the hysterical symptoms in 
general. During the early months of the case there 
were at intervals attacks of athetoic spasms. Usually 
these came and went without appreeiable cause. 
At other times emotion, especially terror from her 
sensory dreams, seemed able to occasion them. They 
lasted from five minutes to hours, were not violent, 
conformed absolutely to the type cases, were bilateral, 
but ceased in sleep, existed only in the hands, and 
several times ceased when Miss J. was exposed to 
some diverting cause. 

The character of these motions differed somewhat 
from the utter irregularity of Hammond's disease. I 
should say they differed unless her attention was 
called to them, in which case no semblance of order 
in the spasms could be seen. When un watched by 
the patient, the motions consisted in constant slight to 
and fro and lateral movements of all the fingers, but 
at brief intervals. A larger range of motion would 
affect first the thumb, and then in turn all of the fin- 
gers in succession from the forefinger to the little 
finger. 

As this woman improved in general condition the 
finger spasms slowly passed away, and have now, I 
believe, been absent for at least a year. Whatever 
doubt there may be as to the hysterical origin of the 
former case, none can exist as to the last one, so that 
we may, I think, rank hysterical athetosis among the 
forms of clonic spasms seen in this peculiar disorder. 



106 DISEASES OF THE NERVOUS SYSTEM 



LECTURE VI. 

TREMOK— CHROXIC SPASMS. 

In" accordance with the plan I have followed here 
of treating at one time of groups of symptoms, at 
another of single S} r mptoms, I shall ask your atten- 
tion to some of the minor forms of motor disorder 
found among nervous or hysterical women. 

The subjects I shall choose are Tremor, or tremu- 
lousness, and certain Spasms, usually local, which are 
not within the range of hystero-epileptic states, but 
coexist with perfect consciousness. 

You have seen here over and over the tremor of 
tobacco, of stimulus, of lead, of old age, and also the 
forms of tremor which are yet more active, such as 
are met with in shaking palsy and sclerosis. Besides 
being thus an expression of weakness, as in old age, 
or fatigue, or the feebleness of convalescence, or of or- 
ganic disease, or toxic states, tremor is a sign in many 
people of transient emotion, of fear, of excitement, 
of anger, or of grief, almost as natural a motor ex- 
pression in some mobile natures as the facial feature 
spasm, laughter or crying, is of uncontrolled mirth or 
grief. Tremor like these, too, is capable, under cer- 
tain circumstances, of passing over the line of healthy 
functional manifestation and becoming a symptom of 
disorder and lack of emotional control. Here we are 



TREMOR — CHRONIC SPASMS. 107 

to consider it as a symptom found often among the 
nervous, a symptom which may be local or general, 
temporary or enduring, and may, in a few cases, be so 
much the most prominent feature of a case as almost 
in itself to constitute a disorder deserving of being 
itself labelled as a disease. 

If the organic tremors, the offspring for the most 
part of coarse textural changes, be clearly spinal, it is 
interesting to ask if the representative tremor of hys- 
teria be in like manner of functional spinal birth, a 
question more easy to ask than to answer; but seeing 
the volitional control which many nervous patients 
possess, as regards the symptom tremor, it seems 
probable that, in extreme cases, the cerebral ganglia 
lose those inhibitory qualities which are usually active 
in the healthy. That, however, this symptom may 
be of mere emotional origin, or derived from patho- 
logical changes, becomes important in diagnosis where 
it sometimes chances that a spinal malady is painted 
on a background of hysteria, or that hysterical 
additions arise in emotional patients to disturb our 
belief that Ave have had to do with a malady purely 
organic. These mixtures of symptoms are, as you will 
readily admit, when you have seen many such cases, 
as bewildering as charades. Some of you may recall 
the case of Miss M., aged 25, a fat and ruddy person, 
who suffered first from overstudy, combined with 
some mental worry. At the age of fourteen she had 
diphtheria, but no sequent paralysis, and came to me 
a few years ago, at this clinic, a person looking as. 
little like having organic disease as any you are apt 
to see. About three years before I saw her she had 



108 DISEASES OF THE NERVOUS SYSTEM. 

had an unfortunate love affair, which had ended in a 
high degree of general nervousness, a form of trouble 
which we have very frequently had occasion to bring 
before you, and the symptoms of which, I trust, are now 
familiar to you. It came on rather abruptly, as these 
things sometimes do, resulting in a tendency to tre- 
mor, which was excited by the slightest emotion, or 
the least excitement or worry, and was always worse 
at the time of her periods. We have also interca- 
lated, in her case, a brief history of occasional hys- 
terical spasm, with spinal and ovarian tenderness. It 
seems probable that on top of this came a condition 
of organic disease of the spine, which is not as yet 
fully developed, but which will in all probability end 
in a general sclerosis, of the character which we call 
disseminated. She has now some slight difficulty in 
walking, vague pains through the limbs, some numb- 
ness of the feet and hands, and slight difficulty of 
speech, a certain drawling, prolongation of her words, 
quite characteristic of the condition in question ; she 
has, too, occasional vertigo, and the disk of her left 
eye is, I think, suspiciously white, while I find, upon 
careful examination, that the vision of that eye is not 
nearly so good as on the other side. The peripheral 
appreciation of colors is distinctly impaired, so that 
there seems to be only too much reason to fear that 
the optic nerves are suffering from atrophic change. 
The tremor she has at present may have been origi- 
nally, and probably was, purely hysterical, since it 
.came and went, and was more or less within control 
of the will. It has now all the characteristics of a 
tremor from organic cause. She cannot thread a 



TREMOR — CHRONIC SPASMS. 109 

needle at all, or eat easily, or carry a full glass to the 
mouth without violent agitation; while the hands are 
for the most part quiet when at rest. Looking at the 
whole of the pecularities of this case, it seems to me 
extremely probable that it has passed quietly, and 
without the suspicion of her physician, into a state of 
organic disease of the spine. 

You are of course aware that there are two forms 
of tremor in connection with spinal troubles; I may 
coarsely state their peculiarities as follows : One" is 
constant while the limb is at rest, and is lessened by 
motion ; and the other is less when the limb is at rest, 
and is made very much worse by voluntary motion. 
The tremor of nervousness, and that which is seen in 
hysteria, may be always constant except in sleep, or 
may come and go irregularly, without apparent cause, 
but will always be liable, like some of the spinal tre- 
mors, to remarkable increase under excitement or ex- 
pectation, or the sense of being watched. It is usually 
a tremor of variable extent, so to speak, the range of 
disturbance, what I may call the width, being greater 
than that of most organic tremors, at least at their 
beginning, while under the influence of emotion, or 
without known cause, it may pass into a condition of 
local or general convulsions, the range of motion in- 
creasing like the lengthening oscillations of a pendu- 
lum, In one respect, however, it distinctly differs 
from the tremors of organic origin, which are never 
notably controllable by the will ; whereas, in people 
merely nervous, or hysterically nervous, it is nearly 
always possible greatly to limit, and sometimes for a 
time to altogether efface the tremor by a sturdy effort 

10 



110 DISEASES OF THE NERVOUS SYSTEM. 

on the part of the patient. The form of tremor of 
which I am now speaking, may be confined to one 
limb, or may be so general, that almost every part of 
the body may be agitated by it, and in these latter 
cases, if the muscles of the face suffer also, they are 
apt to exhibit larger movements, rather than the finer 
tremors which affect the limbs. I remember only too 
well the case of a lady, from one of our neighboring 
counties, which baffled us completely, a year or two 
ago in this hospital. She was a woman, aged 32, thin, 
not anaemic, in fact, rather ruddy. The disease be- 
gan about four years before she came to me, and was a 
general nervousness and neurasthenia, caused by a 
long spell of nursing two of her family through fatal 
maladies. At the close of this effort, which is always 
one of the greatest strains that can be put upon a 
woman, she broke down with hyperaesthetic conditions 
of the senses, with tender spine, with great fatigue on 
the least exertion, and with a general failure of her 
nutritive functions. I do not remember when the 
tremor began, which was so marked a feature of her 
case, but I think it was a year from the time of 
the first outbreak of her symptoms. When alone in 
her room, and thinking herself unobserved, she was 
usually quiet, except for a twitching movement of the 
face, but when anybody entered and especially when 
I myself approached she was seized at once with a uni- 
versal tremor and with extreme general nervousness, 
so that speech became inhibited, and deglutition was 
palsied for a time. 

For some months, at least, the movements were of 
this character, and only after a time grew, what I may 



TREMOR — CHRONIC SPASMS. Ill 

call larger. This was also the history of each onset 
of shaking. The motion rose from trenmlousness 
through large tremor visible to the eve everywhere, 
into a tremor which had in it a certain character of 
violence, and was varied with occasional slight jerks 
of the limbs, and accompanied with perpetual agita- 
tion of every muscle of the face, so that she presented 
an appearance not less singular than distressing. 
This may pass as a good case, in fact, as a rather 
remarkable case of general tremor, but you will 
understand that this symptom in less marked degree 
is very often to be found as an expression of all ner- 
vousness, and even of weakness as in convalescence 
or in old age, while but few old hysterical cases 
escape without more or less exhibition of it. 

Localized tremors, I mean such as are absolutely 
confined to one part, are somewhat more rare, nor do 
I remember to have had the opportunity of exhibit- 
ing to you here a single illustration of this class. I 
have now under my care, however, a very interesting 
woman, who has in both limbs below the knee a con- 
dition of tremor, which is about as fair an example of 
what I mean as anything that I have recently seen. 
In her it was caused by a long strain of nursing followed 
by a disastrous railway accident, in which though she 
herself was not injured, one of her parents was killed. 
It was her general condition for which she came to me, 
and the tremor is to be regarded as only one symp- 
tom. I was told that some time ago, she was the sub- 
ject of general tremor. She seems to have now a con- 
dition of mind not very rare among highly nervous 
women, and which without much straining of language 



112 DISEASES OF THE NERVOUS SYSTEM. 

I might effectually describe as mental tremor. A mo- 
ment of mental indecision seems to trouble her in re- 
gard to everything upon which decision is necessary, 
she revokes her opinion, again decides, and so, but 
with far more uncertainty of mind than is shown in 
her speech, comes at last to a conclusion. Her gene- 
ral condition is exasperated by hysterical anorexia, by 
some dysphagia, and by perpetual and distressing ten- 
dencies to micturition, and by violent flushing of the 
face. Under the influence of tonics, and careful treat- 
ment, she utterly failed to improve, but since I have 
placed her alone, in the care of a a nurse before un- 
known to her, and steadily fed her every two hours, 
with also the daily use of massage, she has so rapidly 
improved, that now there remains very little of. these 
conditions excepting the tremor of which I have spoken, 
but not fully described. While her hands are perfectly 
steady her feet are most of the time, or were most of 
the time, in a state of tremor caused by incessant 
minute activity on the part of the flexors and exten- 
sors of the feet, while there is also a good deal of 
trembling of the leg and thigh. It has lessened from 
above downwards. However quiet her limbs, my 
visit is sure to set them going. She has been taught 
since she came here to restrain these movements by act 
of will, at first for a minute, and now for an hour at a 
time. Aided by the gain in general health, this train- 
ing of the will has proved efficient, and there is at 
present hardly any tremor in the right leg, while that 
of the left is fast disappearing. A well-applied band- 
age in some way helps her, perhaps as she says by 



TREMOR — CHRONIC SPASMS. 113 

keeping her so reminded of the limb as to be able 
to dominate it. 

A year has elapsed since I wrote the last sentence, 
and she is now entirely well. 

What else need be said of nervous or hysterical 
trembling has been already spoken of in conneetion 
with my remarks on the subject of general nervous- 
ness, to which it is so apt to be related. What I most 
desire here is that you should never confuse it, as you 
may easily do, with other tremors, but I must have 
said enough to warn you on that subject. 

Alcoholic tremors can only concern us in their 
diagnostic relationships, and it will suffice if I say, 
that as to this tremulousness, or other neural symp- 
toms, you should be constantly alive to the rare, the 
very rare possibility that your patient may owe 
some of them to the secret abuse of stimulants. I 
say the rare possibility, because in a long and large 
practice among women of the best social class, and 
the one presumed by some people to be prone to 
this vice, I have seen but five or six cases of alco- 
holic drunkenness. I well recall a sad case which 
was brought to me some hundred miles on a couch, 
on account of a shocking state of universal tremor, 
with attacks of prolonged stupor and rarer hys- 
tero-epileptic attacks. The woman had been "diag- 
nosed at," as she told me, by many doctors, and 
took a malicious pleasure in showing me a number of 
opinions. The tremor was incessant and large, but 
did not become worse for my visit, although it was 
at times, I thought, purposely exaggerated, the patient 
being distinctly pleased at the importance of the role 

10* 



114 DISEASES OF THE NERVOUS SYSTEM. 

she was playing. I confess, that I too should have been 
deceived as to this case, had it not been for a practice 
which yon will do well to acquire, a practice now 
become with me a deeply confirmed and increasingly 
active habit of noticing in a room, not only the patient 
but everything else. Missing a bottle of cologne from 
its usual place, where I was apt to make use at 
times of its contents, I said, " Where is your cologne?" 
"My maid upset it," she answered ; " she upset it on 
the table yesterday ; she is very awkward, and did 
the same thing last week." My eyes naturally 
turned to the table, which was of antique mahogany, 
varnished. Now, I had observed that when cologne 
falls on varnish it permanently whitens it, but this 
table was clean of spots. I repeated my question, and 
when the same positive answer came, I was suddenly 
sure that she was drinking cologne, and this proved 
to be the case. We wrung from her and her maid a 
sacl tale of the fraud and stratagems by which she had 
been able to indulge in this singular habit undetected 
for years. 

Chronic spasms persistent through months, or even 
through years of waking life, are rare enough among 
women, but exceptionally rare among even the most 
nervous men. The only cases I recall in these arose 
from nerve- wounds. In my book on Injuries to 
Nerves I quoted but one case, which I had myself 
seen. I saw others which had suffered from violent 
spasm as an immediate consequence of a ball- wound, 
and where, however, the spasm lasted but a few 
hours ; but was in one case so great that the nails of 
the spastically shut hand cut the:palm deeply. 



TREMOR — CHRONIC SPASMS. 115 

You see, therefore, how uncommon is the condition 
of true chronic spasm, and why, therefore, it possesses 
so much interest. 

The chronic spasms of women with hysteria are, per- 
haps, among the most obstinately unmanageable of all 
the graver symptoms of this disorder. They are said 
at times, by the books, to make sudden recoveries. 
My own experience as to this is the same as in hys- 
tero-palsies. I do not see abrupt recoveries — why, I 
cannot say — perhaps because the cases which reach 
me are always old ones, much treated. At all events, 
you must have seen enough here to know that we 
earn our triumphs, as a rule, by intelligent and pa- 
tient care. 

These chronic spasms may affect almost any part. 
You are apt to see the jaw locked ; I have seen it kept 
rigidly open. I have seen the head bent on to the 
breast, and so held for months. The false tumors of 
the belly are local spasms of muscles; such a case I saw 
last year, with Dr. Sinkler, who must well remember 
how the immense tremulousness told us both what 
was the constitutional cause of trouble before the 
woman could uncover her supposed tumor. 

Sometimes you will see these very local contrac- 
tions in a part of other muscles. I once saw two good 
large, permanent tumors in the calf of the leg. They 
were merely contractions of muscle, and not of the 
whole, but of a part, and, like some of the abdomi- 
nal contractions, were very tender. They came very 
near to being removed by a surgeon — -av1io, too often, 
made his diagnosis with the knife. 

I have, however, made mention of some of these 



116 DISEASES OF THE NEKVOUS SYSTEM. 

cases in a former lecture, and need not dwell here on 
this especial form of the trouble in question. 

Permanent spasms, then, may affect almost any 
muscle of the body, and be so violent and lasting as 
to excite our amazement that, through many years, 
in some cases, a few groups of ganglionic cells should 
be competent to evolve such enormous amounts of 
force. I recall from my notes one case, which was, 
I think, a very interesting illustration of these affec- 
tions, and which is also worth mentioning to you, on 
account of the success of the treatment, and because 
of the various therapeutical experiments, for experi- 
ments they must largely be in the treatment of this 
disease, which were made by others or by myself. 
This young lady, Miss C, from Maryland, was brought 
to me a few years ago, as some of my assistants may 
remember, with violent spasm of all the anterior mus- 
cles of the right thigh and leg, the foot, however, being- 
extended. The rigidity of the limb was something 
extraordinary, it stood out, when erect, at absolutely 
a right angle to the body, and no pressure that I dared 
to use was competent to depress it notably without 
causing extreme pain, and soreness of the stretched 
muscles. When the hand was placed upon the ante- 
rior muscles of the thigh they could be felt to be in 
a state of tremor, as though not all of the muscular 
fibres were acting at once. Probably, owing to the 
long-continued action of the muscles, the limb was 
never entirely relaxed in sleep, nor during the many 
months she was at the hospital was it ever seen to be 
in any other position than at a right angle, or at an 
angle of 45° with the line of the erect body. A mul- 



TREMOR — CHRONIC SPASMS. 117 

titude of therapeutic experiments ending always in 
failure, and the abandonment of the case had been 
made by several physicians; nevertheless, I under- 
took the treatment with a certain amount of hope, 
such, in fact, as I always have, when an hysterical case 
is taken away from her own home and social surround- 
ings, and subjected to new and revolutionary influences. 

I began the study of her case by placing her seated 
at the foot of the bed propped up with pillows, and 
then suspended from her ankle an increasing amount 
of weight, to learn whether I could by degrees depress 
the limb, and thus wear out the muscles. I have, 
however, seen her carry a weight of fifty pounds for 
three hours, and she was but a frail girl, without the 
limb falling more than a few inches. Under ether 
the limb relaxed, but there always remained a certain 
amount of rigidity, owing, I presume, to what I may 
call the setting of the too long-contracted muscle. 

Long before the ether left her, the spasm returned, 
and, therefore, I was quite sure that it was not one of 
those forms of mimic spasms of which I have presented 
to you some curious examples. I next made an effort 
to wear out the spasm by the use of induction currents, 
using two batteries, but although I employed such a 
power of the batteries as could not readily be sustained 
by any but an hysterical woman, I did not succeed in my 
efforts, and she remained much as before. The use of 
galvanism to the spine, no matter what might be the 
direction of the current, also failed. She was finally 
cured by very much gentler treatment, which con- 
sisted in the use, twice a day, of the fullest hypo- 
dermic injections of atropia she could bear thrown 



118 DISEASES OF THE NERVOUS SYSTEM. 

directly into the rigid muscles. As soon as the 
atropia began to show its power in a certain amount 
of relaxation of the limb, I also had the limb manipu- 
lated, having it moved in different directions, upwards, 
downwards, and sideways. Under this treatment she 
steadily improved, and finally left the hospital able to 
walk on crutches, with the limb nearly straight under 
her, but still unable to employ it in walking. By this 
time she had obtained a certain amount of volitional 
control over its action, and in a few months became 
entirely well. There are cases, however, in which 
steady extension of the flexed limb, or steady flexion 
of the extended limb by apparatus will succeed in over- 
coming this rigidity. Of this I have seen an excellent 
example in the case of Miss TV\, also from Maryland, 
who came to me with the diagnosis of general sclero- 
sis, but who really presented one of the most extraor- 
dinary illustrations of hysterical symptoms which I 
have met with in years. She had at one and the same 
time some general palsy, a profound loss of power of 
the left leg, anaesthesia, and chronic hysterical spasm 
of the right leg, with violent alternate spasms and 
extensions of the head, together with a quite marked 
amount of mental hebetude, somewhat rare in such 
forms of hysteria. To make her case still more diffi- 
cult, I may add, that she was fat and rosy, in perfect 
condition, menstruating with ease and regularity, and 
apparently suffering from no organic trouble whatso- 
ever. I say to add to the difficulty, because I always 
feel more hopeful of a case of hysteria when it occurs 
in the person of a woman lean, wasted, and anaemic. 
You have then, of course, the chance when building 



TREMOR — CHRONIC SPASMS. 119 

up a constitution, to aid your moral treatment by all 
of the profound alterations which you may bring 
about during the process of fattening, and tilling with 
good blood an exhausted system. In her case I suc- 
ceeded in extending the limb by the use of a screw 
apparatus, and a stirrup fastened to the extended foot, 
and attached to the apparatus below the knee. Per- 
haps the anaesthesia of the limb may have aided me 
in this matter, but, as I have said above, it is not often 
that you succeed by these means, and in using them 
you may expose your patient to a second disorder in 
the form of general convulsions, or local spasms in 
parts remote from that first affected. 

I saw an example of this in the case of a lady whom 
I went to Massachusetts to see, some years ago, and 
who suffered from atrocious chronic spasm of the left 
arm, so that it was always painfully flexed. There 
was no anaesthesia of the limb, and every effort to 
make it straight gave rise, if persisted in, to general 
convulsions, which finally caused, as you may imagine, 
the total cessation of all efforts in that direction. 

The treatment of these forms of spasm must con- 
sist in the treatment of the ereneral condition, and of 
what that is, I have already fully spoken, in speaking 
of the general subject of the course of hysteria. 

I have seen tendons cut for these cases, an opera- 
tion to which surgeons are rather too prone in my 
opinion. I cannot remember a case which was re- 
lieved by such an operation, while the use of atropia 
hypodermically, and of the slower but gentler method 
of manipulation, and in a few cases of extension by 
instruments, will in a certain number, assuredly not 



120 DISEASES OF THE NERVOUS SYSTEM. 

in all, bring about a permanent cure. Spasms such 
as these, are not often mimicked, but occasionally 
you will meet with an illustration in this form of 
that unconscious simulation of disease, if I may be 
allowed such a phrase, of which I have already so 
frequently spoken. In this, and in the mimicked pal- 
sies which are yet more rare, there occasionally arises 
the chance for those abrupt impressions upon a patient 
which so amaze alike the sufferer and her friends. 
I recollect, as an illustration, the example of a very 
charming young girl from Ehode Island. When I 
first saw her she was lying on the bed, with her 
knees drawn up, her feet not extended as is usual, but 
flexed. I was told that when she awoke in the morn- 
ing, they were straight, but were almost immediately 
drawn up into the state in which I saw them. After 
going over her whole system and not discovering evi- 
dences of organic disease, I finally made up my mind 
that it was a case for one of those bold experiments 
which sometimes succeed when more timid action 
fails. After inducing her mother to leave the room, 
I suddenly straightened one of her legs. I met with 
no difficulty until I had partially attained my ob- 
ject, and this proved to me with certainty, that it 
was a willed spasm with which we had to deal, and 
not one controllable by volition. I then said to her, 
" I have straightened one of your limbs, straighten 
the other for me." She said, " I cannot, but perhaps 
you can." I straightened it with but little difficulty. 
I then said, "Sit up on the side of the bed." She replied 
that she had not sat up for years, but I finally got 
her seated with much trouble, and then, picking up a 



TREMOR — CHRONIC SPASMS. 121 

gay cravat, and tying it around her neck, I said, laugh- 
ing, "Now you are all dressed for a walk, how amus- 
ing it would be to meet your mother at the door." To 
my surprise she yielded, seeming to enter into the fun of 
the idea, and with a staggering gait (such as you would 
expect from one long confined to bed) she advanced 
with me to the door, where she met her astonished 
parent who was just coming into the room. She 
never went back to bed again permanently, and in a 
few weeks afterwards was able to ride on horseback. 

You now and then meet with cases in which the 
whole range of hysterical phenomena leap into mis- 
chievous life owing to some most trivial wound or 
other hurt, but it also chances at times that a real 
and grave injury of a nerve may give you an 
almost indistinguishable mixture of nutritive and 
other disorders the usual result of nerve wounds, and 
also of hysteric symptoms such as may perfectly well 
arise without traumatic cause. It becomes then al- 
most impossible to say of a given symptom, such as 
chronic spasm, which may be the child of either parent, 
whether it be hysteric or due to the nerve lesion, and 
yet as concerns treatment, it may be of the utmost 
moment to reach such a decision. The following case 
is a remarkable illustration of my meaning. 

I saw last year, with Dr. Morton, P. L., set. 26, a 
maid-servant, who had, a year ago, a fall in which 
she bruised her left side. Being of a nervous and 
impressible nature, it was not surprising that she 
was seized at once with left unilateral numbness 
and slight loss of power. These symptoms faded 
away in a few days as one of the minor injuries due 
11 



122 DISEASES OF THE NERVOUS SYSTEM. 

to her fall rose into mischievous prominence. In 
falling, she struck her left elbow so as to cause pain 
down the arm, but not in the ultimate distribution of 
the ulnar nerve. Five days after the accident the 
pain grew worse, and a general hyperesthesia spread 
over the ulnar side and middle of the arm. At the 
same time the ringers began to flex more and more, 
until at last all the finger-tips and the thumb came 
into contact in the position assumed when with all of 
the fingers we hold some small object. The hand was 
held in extreme and constant flexion chiefly by spasm 
of the palmaris longus, the tendon of which was rigid 
and prominent. The least effort at passive motion of 
the parts caused intense pain, and the hyperesthesia 
was so great that a touch on any part of the fingers, 
except the thumb and forefinger, and on nearly the 
whole forearm seemed to occasion the utmost distress. 
This case, I confess, somewhat puzzled me. Nerve 
wounds of themselves give rise in either sex to hys- 
terical states, so that, except for my knowledge of the 
previous temperament, this condition was of little 
diagnostic aid. The hyperesthesia was extreme. It 
is so in many nerve wounds or contusions, but, at 
least early in the case, it does not pass out of the dis- 
tribution of the nerve presumably affected. In this 
case it did not seem to have anv accurate anatomical 
site, that is, it was partly in the ulnar, and irregularly 
there, and in a portion of the median and musculo- 
spiral territories ; while there was none of the tactile 
loss which inevitably accompanies nerve lesions, there 
being agonizing pain, and yet lack of accurate sense 



TREMOR — CHRONIC SPASMS. 123 

of touch. Besides this, in the present case, the fingers 
were cold ; there were no joint lesions, nor any caus- 
algia or nutritive changes in the skin or nails. When, 
too, I pressed on an indifferent point — such as the 
olecranon process — and led her to believe that I was 
compressing a nerve, she described her increase of 
pain as terrible. Either, then, this was a case of slight 
nervous lesion exasperated by the hysterical tempera- 
ment, or else it was not a nerve hurt of any gravity, 
and all of the symptoms had arisen in consequence 
of a trivial hurt, just as a pin-prick may be the start- 
ing-point of the most extreme and enduring hysterical 
phenomena. It would, I think, be difficult to find a 
better illustration of the difficulties in reaching a dis- 
tinct diagnosis in such cases, and yet a diagnosis is 
here, if in any case, most desirable, because, if the 
case be purely due to contusion of the ulnar nerve, 
the question of operative interference is certain to 
arise should the symptoms continue long. This 
woman was put under the daily use of galvanism to 
the arm and hand. Each application was followed by 
relaxation of the contracted parts and by a lessening 
of the hyperesthesia. When the poles were applied 
without making circuit, the same results followed, and 
I have now not the faintest doubt that the phenomena 
were from the beginning to the end of purely hysteri- 
cal parentage. 

There is a form of spasm which is sometimes mis- 
taken for paralysis, and is to be met with, as far as I 
know, only among women ; that is to say, in a large 
experience I have never encountered a case among 



124 DISEASES OF THE NERVOUS SYSTEM. 

men ; it is what I might call spasmodic ptosis. It is 
to be distinguished from that violent closure of the 
eye which is found with or without some disorder 
of the fifth nerve, by the fact that it is simply a 
quiet shutting of the lid, and a resistance on attempt- 
ing to lift it up with the fingers, and an absolute 
incapacity for a time to raise it by the will. If 
this were a paralytic feebleness, there would, of 
course, be no difficulty in pushing up the eyelid with 
the finger, but, as I have just stated, this cannot be 
done without the exertion of a good deal of force. 
I fancy that, even among women, this condition is 
rare, as I do not remember seeing more than three or 
four instances. I mention them as curiosities and as 
cases which you may occasionally see. There is also 
a paralytic ptosis which is common among women, 
and which I hope you will not confound with the 
malady with which we are now dealing. The last 
example I have seen of spastic ptosis was in the per- 
son of a lady, who came from the interior of Pennsyl- 
vania, and who has since died of cancer of the stomach. 
She was a person easily tired, emotional, and low- 
spirited at the same time. She suffered also from 
nasal catarrh, and had, like most of these cases, no 
photophobia. During the winter previous to her visit 
to me she began to have, without known cause, a 
closure of the lids. They would remain closed for 
several hours at a time, and then would open with 
probably as little cause as they closed. I saw her 
twice before I obtained an opportunity to see this 
symptom. She then seemed to be unable to raise the 
eyelid, and I could not lift it without a considerable 



TREMOR — CHRONIC SPASMS. 125 

amount of effort. I treated her for a long time, and 
in various ways, and she had at different times tried 
galvanism and electrieity and many other forms of 
treatment. Section of the supraorbital nerve had 
been proposed to her by an enterprising surgeon, but 
she got well apparently unaided by physicians, and 
died, as I have said, four years afterwards of malig- 
nant disease. Another case was in a woman of great 
intelligence and remarkable accomplishments who had, 
I think, injured her brain by excessive devotion to 
study. She had no disease of the eye proper, nor any 
organic malady, nor could I say that she was a notably 
nervous woman. She had, however, been from child- 
hood a shy person, subject to blush too easily, and at 
times excessively embarrassed by the presence of 
strangers. The trouble of her eyes came on for the first 
time at a watering-place. When going to dinner, and 
sitting down, she observed that a great number of per- 
sons were looking at her as a last arrival- she mentioned 
the fact to her husband, and was almost immediately 
attacked by a violent closure of the eye, and was 
obliged to be led in this condition from the table. 
"When this had happened once, you may well imagine 
that every repetition of the original eause brought 
back a return of the disorder, until at last it was quite 
impossible for her to go to table in the room with 
other people. You will see that in this case emotion, 
and, after the establishment of the symptom, the des- 
potic control of an unpleasant memory were competent 
to create and then to continue this grave inconvenience. 
I succeeded in inducing her, however, to make an effort 
to go to dinner, without regard to what happened, and 

11* 



126 DISEASES OF THE NERVOUS SYSTEM. 

to face the slight unpleasantness and the talk which 
her appearance might create. Her courage was final- 
ly rewarded by a cure, which was perfected, so to 
speak, by a long absence in Europe, and constant ex- 
posure to the very difficulties which had given rise to 
her first attacks. 



CHOREA OF CHILDHOOD. 127 



LECTURE VII. 

CHOREA OF CHILDHOOD. 

Some years ago I was struck with the rarity of the 
true chorea of childhood among negroes, of whom a 
fair proportion applied for aid at my clinic. In the 
hope of securing more full information as to this 
question, I asked my friend, the late Professor Henry, 
of the Smithsonian Institution, to distribute in the 
Southern States a circular, asking the following ques- 
tions : — 

1. As to the frequency of chorea in white children. 

2. As to its relative prevalence in localities. 

3. As to its relative frequency in black children of 
pure breed. 

4. As to its frequency in mulattoes. 

5. As to the season of greatest frequency of attacks. 
This circular was sent, for the most part, to the 

meteorological and other observers, who were corre- 
spondents of the Smithsonian, and through them to 
their friends. It reached thus a very intelligent class, 
and fell into the hands of secretaries of State and 
county medical societies, who were at much pains to 
give me the collective experience of large numbers of 
practitioners. 

Had all, or nearly all, of my circulars been an- 
swered, I could have quite fairly mapped out the 



128 DISEASES OF THE NERVOUS SYSTEM. 

relative prevalency of chorea as to States. As it was, 
my replies gave me the experience of two hundred 
and ten physicians scattered through the towns and 
rural districts of the South and Southwest. The in- 
formation thus obtained is very interesting, and, how- 
ever incomplete it may be, is too curious to be laid 
aside. In the hope, therefore, that it may awaken 
ampler and more exact research, I have ventured to 
analyze it. No one can feel more fully than I how 
much it lacks of being perfect as evidence, or how 
largely it is open to criticism on account of the fal- 
lacies, which are apt to pervade information thus 
obtained. 

The points with which I shall deal will be: — 

The relation of the chorea of childhood — ■ 

To season and meteorological conditions. 

To climate. 

To locality, town or country. 

To race. 

Forms of chorea. 

Relation to season. — It became clear, many years 
ago, to every one who followed my clinics, that as the 
cold of winter faded away, and the changeful weather 
of March and April prevailed, cases of chorea became 
frequent. This continued to be the case until, with 
the warmer season, the number fell away, remaining 
then at about the same ratio through the autumn and 
winter months. 

These facts were so striking that at my desire Dr. 
Gerhard collated all the available cases from the note- 
books of the Infirmary for Nervous Diseases, in order 
to arrive at an accurate determination of this point in 



CHOREA OF CHILDHOOD. 129 

the natural history of the disease. Soon after, Dr. 
Mills published a like summary of cases from the 
clinic books of the University of Pennsylvania; and 
within a few days Dr. Morris Lewis has kindly 
brought together all of our own cases which have 
presented themselves since the date of Dr. Gerhard's 
paper, with additions from my private note-books. 
This experience thus covers all classes of society. 

Dr. Gerhard found that my clinic and note-books of 
private cases gave for the time of attacks of sixty- 
eight cases of chorea, thirty-nine in the spring 
months, ten in the summer, seven in the autumn, 
and twelve in the winter. This result was sufficiently 
striking, but was incomplete, because the months of 
attacks were not indicated. The subject seemed to 
me to promise interest enough to repay a more exact 
study, and for this purpose an effort has been made 
to relate the attack to months instead of seasons, and 
to examine into the conditions of weather which are 
to be found in periods of the greatest and least fre- 
quency of chorea. For the intelligent study here 
made of this difficult subject I am largely indebted 
to the skilful industry of Dr. Morris J. Lewis. 

A few years ago no such study would have been 
possible, but, the resources of the Weather Bureau 
having been put at my disposal, I have found no ob- 
stacle, save in the changes of the method of nota- 
tion in its tables which have been made from time to 
time. 



130 DISEASES OF THE NERVOUS SYSTEM. 



EXPLANATION OF TABLE I. 

Line 1. Interpreted by using column of figures to 80 ; is 
intended to represent the mean relative humidity, i. e., 
the mean per cent., and not the mean actual amount, of 
the moisture which could be held in solution at the mean 
temperature of each month ; the amount representing com- 
plete saturation being indicated as 100, — the mean for the 
month being obtained from the daily mean relative hu- 
midity. 

Line 2. Interpreted by using the column of figures 29.70 to 
30.30; is intended to represent the mean barometric read- 
ings for each month. 

Line 3. Interpreted by using the column of figures to 80 ; is 
intended to represent the mean thermometric readings for 
each month. (Fahrenheit scale.) 

Line 4. Interpreted by using the column of figures to 80 ; is 
intended to represent the actual rainfall or melted snow in 
inches for each month. 

Line 5. Interpreted by using column of figures to 80 ; is 
intended to represent the months of 'onset of 170 separate 
attacks of chorea. 

Line 6. Interpreted by using column of figures 10 to 20; is 
intended to represent the mean daily range of tempera- 
ture for each month. This is obtained by subtracting the 
mean of the minimum temperatures, of each month, from 
the mean of the maximum temperatures of the same, and 
is an indication of the variableness of the different months. 



EXPLANATION OF TABLE II. 

This table is merely a mean of the five years 1876-80, and is 
interpreted in the same manner as Table I. 



CHOREA OF CHILDHOOD. 131 



EXPLANATION OF TABLE III. 

Line 1. Is intended to represent the actual number of days on 
which rain or snow fell in the diiFerent months of the 
years 1876-80. 

Line 2. Is intended to represent the actual number of cloudy 
days during the same period, — the cloudy days being deter- 
mined by the following rule : "In determining whether a 
day is clear, fair, or cloudy, its character will be deter- 
mined by taking the sum of the entire number of fourths 
of clouds, observed at 7 A. M., 2 P.M., and 9 P. M. A 
clear day will be one in which the sum of observed fourths 
is 3, or less than 3 ; a fair day, one in which the sum is 
from 4 to 8 inclusive ; and a cloudy day, one in which the 
sum is from 9 to 12 inclusive." 

Line 3. As in Table II. ; is intended to represent the months of 
onset of 170 separate attacks of cliorea. 



EXPLANATION OF TABLE IV. 

Line 1. Is intended to represent the number of storm centres 

passing within 750 miles of Philadelphia during the years 

1878-80. 
Line 2. Is intended to represent the number of storm centres 

passing within 400 miles of Philadelphia (1878-80). 
Line 3. Is intended to represent the months of onset of 87 

separate attacks of chorea (1878-80). 



132 DISEASES OF THE NERVOUS SYSTEM. 

Remarks and conclusions. — In drawing conclusions 
from these tables, it must be remembered that, while 
the meteorological portion is complete as far as carried 
out, the number of attacks of chorea represented is 
by no means the complete number occurring in Phila- 
delphia during the five years under consideration, but 
is merely a list of as many separate attacks as could 
be collected, where the month and year of onset were 
known without doubt. 

In glancing at Table II. it is seen that the chorea 
line (5) suddenly rises to a very high point in March, 
this month having 35 attacks, or 20.58 per cent, of 
the whole number; the line then falls suddenly in 
April, then rises slightly during the summer, to fall 
again and reach its minimum in October, viz. : 6 
attacks, or 3.52 per cent. ; after this a very slight rise 
occurs. In comparing this line with the line of mean 
temperature alone (line 3) nothing especial is seen, 
the same temperature in the autumn, as in the spring, 
not being accompanied by an increase of the disease ; 
nor is much light thrown on the subject in comparing 
it with either the line of the mean relative humidity 
(line 1), or with that of the mean barometer (line 2), 
except that there appears to be an increase of chorea 
with a fall in the mean relative humidity and baro- 
metric tracings, and vice versa. This can also be seen 
in Table I., but not as plainly as in Table II. 

It has been stated that the disease is most preva- 
lent during moist, cold weather ; but this assertion 
does not appear to be sustained by Table II., where 
it is seen by comparing the lines 1 and 3 that January, 
February, and December have a much lower mean 



CHOREA OF CHILDHOOD. 133 

temperature, and a much higher mean relative humid- 
ity than March, and yet these months have but a small 
proportion of attacks. 

Nothing of any apparent importance can be gleaned 
by comparing the mean daily range of temperature 
(line 6) with the chorea line. 

In comparing the amount of rainfall and melted 
snow per month (line 4, Table II.), with the chorea 
line, there appears to be a slight coincidence, the lines 
rising and falling together except in May and June, 
although the amount of rainfall is not proportionate 
to the number of attacks. In looking at Table III., 
it is seen that the line representing the actual number 
of cloudy days (line 2) bears a much closer resem- 
blance to the chorea line than does that of the actual 
amount of rain and snow (line 4, Table II.). In July 
and August there appears to be a discrepancy between 
the two, but in other respects the resemblance is 
marked ; the maximum attacks of chorea, occurring 
in March, coinciding exactly with the greatest number 
of cloudy days, and the minimum, in October, coin- 
ciding with the minimum number of the latter. The 
increase in the number of cloudy days in November 
does not have a proportionate number of attacks of 
chorea, although a slight rise is perceptible. 

Allowance must be made here for the method of 
computing the cloudy days, as the rule previously 
stated is not without its objections ; for by this it may 
rain, or there may be a thunderstorm on a clear or fair 
day. The line representing the number of days upon 
which rain or snow fell (line 1, Table III.) also resem- 
12 



134 DISEASES OF THE NERVOUS SYSTEM. 

bles, in some respects, the chorea line. This point will 
be referred to further on, after a study of Table IV. 

Line 1 of this table represents the number of storm 
centres that have passed within a circle, whose radius 
is 750 miles, drawn round Philadelphia as a centre, 
during 1878-80, inclusive. The two previous years 
were omitted, as the storm records were not available. 
It was originally intended to construct a table show- 
ing the number of storm centres that passed within 
circles of varying radii ; but as it was seen that the 
resemblance between the storm and chorea lines in- 
creased as the circles increased in size until the largest 
with 750 miles radius was reached, it was concluded 
to simplify the table by only tracing the lines that 
represent the number of storm centres passing within 
the circles of 750 and 400 miles radii respectively ; 
the latter line (2, Table IY.) being inserted to corro- 
borate the statement just made. 

The reason of the resemblances between some of the 
lines in Tables II. and III. now becomes more appa- 
rent, as they may be considered as component parts of 
a storm, or as some of the factors of a storm, so that 
a partial resemblance between them might reasonably 
be expected. A conclusion which it seems justifiable to 
draw from the foregoing study is, that no single factor 
of a storm explains satisfactorily the rise and fall of 
the chorea line, but it is where these are taken collec- 
tively, as in the storm line, that the greatest resem- 
blance is seen. 

It is worthy of note here that the chorea line of 
Table IY. resembles, in all its important features, the 
chorea line of Table III., although there are 83 fewer 



CHOREA OF CHILDHOOD. 135 

attacks included in it, so that it is reasonable to sup- 
pose, if a larger number of attacks could be collected, 
the resulting line would resemble those depicted in 
the tables. 

It appears that the area over which a storm has its 
influence is strikingly alike in chorea and in neural- 
gia, as proved by my former studies in the case of 
Captain Catlin. 1 

It will be seen with what extreme caution we have 
ventured to draw conclusions from the elaborate 
study here made. It is at all events valuable as a 
step in a good direction. 

The facts which come out here so clearly as to the 
time of choreal attacks and their relation to storm 
states would seem to indicate the further need for a 
yet more refined and careful study of other points. 
It were most desirable in future to set apart the cases 
of chorea from fright and to study alone those cases in 
which rheumatism accompanied or preceded this dis- 
ease, while it would be also most interesting to learn 
how far the curve of acute inflammatory rheumatism 
would compare with that of choreal frequency. 

It is of course probable that other factors than 
conditions of weather may have a share in multiply- 
ing attacks. One of these is certainty the influence 
of mental labor. I know of many, cases which get 
well when they cease to study, and relapse at every 
new effort to do school work. With us the public 
schools have their most important examination in 
June, when promotions are made and class rank deter- 

1 Am. Journ. Med. Sci., April, 1877. Relation of Pain to Weather. 



136 DISEASES OF THE NERVOUS SYSTEM. 

mined. The pressure on the children is often con- 
siderable, and may have its share in the rise of the 
chorea line in early summer. 

It is interesting, as we pass from this subject, to 
pause a moment in order to contrast with chorea, an- 
other neural malady as regards their meteorological 
factors. 

Some time ago my colleague, Dr. Wharton Sinkler, 
showed that the paralysis of childhood is most com- 
mon in hot weather. He has now, at my request, 
made out the curves of relative monthly frequency 
of this disease as seen at our clinics since 1872, and 
has added the curve of temperature. (See Table V.) 

The gradual rise to a maximum in August suggests 
disastrous preparation by the weather of July, our 
month of greatest heat; and the minimum reached in 
winter is certainly a fact which no previous theory of 
this disease could have prepared us to suspect or an- 
ticipate. 

Recurrence of Chorea. — The tendency of chorea to 
recur is mentioned by several authors, and especially 
by See. He speaks in one case of six, and in another 
of seven returns; and, what is most interesting, he 
fixes on the autumn as the time of relapses, as well 
as of the initial outbreaks, and thinks that each suc- 
cessive attack is apt to be lighter than the last, which 
has certainly not held good in my own experience. 
The French authors who mention any time for occur- 
rence or recurrence of this malady all follow See's 
statement. According to him, the six autumn and 
winter months furnish three-fifths of all the choreas. 
This he attributes to the joint action of cold and 



CHOREA OF CHILDHOOD. 137 

moisture, which seem to him the most important 
factors, but which, as our tables show, does certainly 
not hold good as regards this country and latitude. 

Dr. Gerhard's paper mentioned the facts observed 
in this direction at my clinic, and in my private prac- 
tice. Out of 80 cases, 25 bad been attacked before. 
Of the 25 cases, 14 had thus had chorea three times; 
8 had had it twice; and 3 had experienced it four 
times. Of the 25, nineteen recurred in the spring. 

My later experience has given me cases of chorea 
which have recurred in a yet more remarkable man- 
ner. One young girl had chorea for four years either 
in March or April; then once in February; and then 
for two years in May. In another case the disease 
broke out in a lad aet. twelve, and recurred every 
spring for three years. In a third case, the disease 
began in a girl of seven, and missing one }^ear per- 
sisted until she was thirteen, when it ceased to appear. 
The attacks began usually in March or April. 

I never knew a case to recur thus pertinaciously 
in the autumn, although sometimes, in this latitude, 
vernal attacks get well in summer, and recur in au- 
tumn. The same holds good of winter chorea. If 
cured, there is a positive tendency to break out in 
the spring. 

Dr. Morris J. Lewis's table of my own clinics gives 
this result as to repetitions of attacks: 126 cases, 
representing 185 attacks. 

Sinee I have been well aware of these facts, I have 
been accustomed to warn parents of the tendency of 
chorea to recur, and have always given careful in- 
struction as to the general treatment of the child in 

12* 



138 DISEASES OF THE NERVOUS SYSTEM. 

winter, and have always given arsenic as the spring 
began. I have in this way broken up, in many cases, 
the habit of vernal recurrence of chorea. 

How far such facts hold good of other latitudes than 
this I cannot yet say; but I gather from many of the 
letters of answer I received from our warmer States, 
that the onsets of this disease are probably more com- 
mon in winter than with us. I have no accurate 
numbers wherewith to settle the question. It would 
be very interesting to know what law of occurrence 
and recurrence chorea follows in Great Britain. 

Relations of Chorea to Climate. Locality. — After I 
had determined the factor which I have here illus- 
trated, I became somewhat interested in the question 
of climate as related to this disease, and was soon 
struck with the slight information on this subject to 
be found in the books. Yon Ziemssen says that 
Hirsch has now authoritatively contradicted Kufz's 
statement of the rarity of this disease in the warm 
zones both in black and white. Its relative frequency 
is hard to judge of, because there is little or no death- 
rate, and because cases are sometimes noted as deaths 
from chorea, when they were due to other maladies. 
Hence the only evidence is the statement of physi- 
cians in active practice. 

If I consider this, I should conclude from the 
answers to my questions, that warmth does not nu- 
merically lessen it, as in fact my tables show. It 
appears to exist in all of the larger cities all over 
our Southern States, and also quite freely in Cuba. 
Dr. Finley, of Havana, and Drs. Landetta and De Cas- 
tro, formerly of that city, report it as common enough, 



CHOREA OF CHILDHOOD. 139 

especially among girls at the approach of puberty. I 
hear like accounts from Lisbon and from the great 
cities of South America. In a few cases Southern 
physicians write me that it is rare even in large towns, 
but when they add the number of cases they have 
seen, it is usually clear that they have met with quite 
as much of this disease as it is common to encounter 
at the North. The facts already pointed out, which 
show clearly enough that chorea is seen most in the 
spring and early summer, might very well prepare 
ns to find least of it in such localities as the Ber- 
mudas, where the temperatures vary so little through- 
out the year ; but as to this I have no information. 

There is another factor in the case, and an impor- 
tant one. It comes clearly out in the answers I re- 
ceived. Chorea is a disorder engendered in some way 
by the evil influences which are found wherever men 
live crowded together in masses. It is essentially a 
disease of cities. The larger cities, both in the north 
and south, furnish it, as I should judge, in much the 
same proportion. There is less in the smaller places, 
and in country practice, north and sonth, it is an ex- 
ceptionally rare disease. Physicians who have been 
twenty to forty years in rural practice, sometimes 
cannot recall a case, and yet, as we know, rare cases 
are usually the best remembered. Among one hun- 
dred letters, were twenty representing — and it is no 
bad way to put it — over three hundred years of prac- 
tice by men who have never seen a case of chorea. 

I should at least have expected to find, that, in 
highly malarious countries, where, as we know, the 
endemic influence tells severely on the health of all 



110 DISEASES OF THE NERVOUS SYSTEM. 

ages, this lowering cause would be competent to do 
what some combination of atmospheric causes en- 
ables the spring and summer months to do — awaken 
chorea, There is, however, no evidence to favor the 
view that chorea can have a malarial origin, except 
that it arises in spring with as much certainty as ague. 
But there is also some direct evidence to show that 
there may even be something hostile in malaria to 
chorea — a point which I make with considerable 
doubt. It would seem, however, that, in localities 
where malarious plains are bounded by wholesome 
hills, — as a most excellent observer, Dr. Ellis, of 
Elkton, declared, and some other physicians also, — the 
chorea which they met with arose on the hills, and 
not on the plains. To this I should add, that, in cer- 
tain of the most malarious regions of the South, 
chorea is a nearly unknown malady. 

It would naturally follow upon what I have said, 
that the disease itself would be found to increase nu- 
merically in cities in direct proportion to their growth. 
Of the increase of a rarely mortal disorder we can, 
however, have no just conception, and the deaths 
reported as due to chorea must, as I have said, be 
regarded with a certain amount of suspicion, and this 
remark will especially apply to years long past when 
there was far less accuracy of discrimination as to the 
causes of death from neural maladies. 

The slightest study of the vital statistics of our own 
cities will show how just is this criticism. In Chicago 
from 1851 until 1866 there is no report of a death by 
chorea at any age Then in 1866 there is one, a girl 
of 15 years, and then none to 1869, where my statis- 



CHOREA OF CHILDHOOD. 141 

tics fail me. The population had meanwhile increased 
from 38,000 to 252,000. 

In Philadelphia, between 1807 and 1881, chorea is 
given as the cause of death in 64 persons, of whom 38 
are said to have been under 20 years, and 26 over 
that period of life. In this list are many over fifty 
and many under two years, so that there were prob- 
ably in these two sets a fair proportion of imperfect 
diagnoses. 

Race. — Although aware of the insufficiency of the 
material on my hands to answer thoroughly this ques- 
tion, I have felt unwilling not to use the letters which 
so many gentlemen have been at great pains to write 
me. I have, however, hesitated the more because 
the tentative opinion on this question which I reached 
quite early, has been criticized by very able southern 
physicians as not in accordance with the facts they 
themselves had observed. 

Let me admit, to begin, that in these letters there 
may be many errors; that rare cases may be for- 
gotten ; that the negro often fails to call on a doctor 
for even serious maladies ; and, granting these sources 
of distrust of my statistics, I do not see how we can 
fail to conclude as I have done, not that the negro is 
insusceptible of having chorea, but that in the black 
race it is far more rare than in the white. 

Of sixty physicians who replied at length — some 
lived in cities or towns, some in the country — twenty- 
seven speak of chorea as rare in the white ; all of the 
rest give the number, or an approach to the number, 
of white cases they can recall. One has seen an epi- 
demic outbreak of chorea. Of these sixty, forty-nine 



142 DISEASES OF THE NERVOUS SYSTEM. 

have never seen chorea in the black ; the rest who 
write speak of it as rare, or mention having seen single 
cases. I should add that many of the examples spoken 
of were women, but exactly of what ages is rarely 
stated. 

Even this curious correspondence of view does 
not, however, impress me so much as the character 
of the writers of some of the letters and the extent 
of inquiry which they have made. It may be well 
worth while to analyze portions of this evidence. 

Dr. B. De Landetta says, as regards Cuba, and two 
others indorse his opinion: "I have never seen 
chorea in the negro, which is strange, because it is 
rather frequent in Cuba among white girls at puberty, 
and because rheumatism is common in the negro." 
Dr. Ch. Finley, of Havana, thinks chorea rare among 
whites; but, despite his appeal to the Havanese 
Academy of Medicine and the publication of the 
questions in its journal, but one case of chorea in 
the black could be heard of. 

Among the letters are several from physicians who 
had been large owners of slaves, and had also had 
extensive plantation practice. One, Dr. Ashe, of 
Alabama, having seen in all seven white cases, never 
saw a case in the negro. 

Dr. Benj. Lee writes that in a year of service in 
the Hospital of the Home for Colored Children, New 
York, he saw a case of chorea in a mulatto girl set. 15 
end fatally, but has never seen it in the pure black. 
Dr. Kolloek writes me from Cheraw, S. C, that he 
has seen in twenty five years of large practice some 
twelve cases in the white and two in the negro of 



CHOREA OF CHILDHOOD. 143 

pure breed. Three physicians write me from Louis- 
burg, N. C, that one of them in thirty-six years of 
practice recalls six or seven cases and one death in 
whites. Two others have seen a few white cases, and 
none of the three any black cases. Prof. J. L. Cabell 
recalls but five cases in the white, and has seen none 
in the black. Prof. Bemiss, of New Orleans, has seen 
cases both in white and black, and does not feel sure 
as to this question. Dr. Ellis, of Elkton, Md., a most 
competent observer, has obtained, by careful inquiry, 
knowledge of thirty cases in the white in ten years, 
and of two in black or colored children. Dr. Michel, 
Montgomery, Ala., writes me that no one of the thirty 
members of their County Society ever saw a case in 
the pure negro. The disease is seen in whites. The 
secretary of the Medical Society of Columbia, S. C, 
from correspondence in the State and from the debate 
on this subject in the society, was unable to discover 
a case of chorea in the negro. 

Dr. Peyre Porcher, having put this question to thir- 
teen members of the Charleston, S. C, Medical Society, 
received for answer that the disease is not common 
among whites, and that no one of the number had 
seen a case in the negro, and to this, Prof. E. Geddings 
adds testimony to the same effect. Dr. Laurance, of 
Hot Springs, Ark., says chorea is found very rarely 
among negroes, more often among mulattoes, but is 
not a common disease where he has lived in the South. 
The general evidence in Yirginia is very much to this 
effect, but in Eichmond it is clearly. less infrequent, 
both iu white and black or colored, than elsewhere in 
the State. 



144 DISEASES OF THE NERVOUS SYSTEM. 

On the other hand, many physicians in Virginia 
state that it is as common in one race as in the other, 
and Dr. Landon Edwards, of Eichmond, after a careful 
inquiry, reached the conclusion that the negro has no 
immunity. 

It seems to me, however, that as the matter stands, 
the weight of evidence is in favor of the opinion that 
the black is less liable to chorea than is the white. 

Varieties of Chorea. — I pointed out some years ago, 
that there exist at least three groups or species in the 
genus chorea of childhood. The significance of the 
distinctions is not as yet clear to me, but I am in- 
clined to think that they may indicate a differentia- 
tion in the anatomical sites of the central disturbances 
which give rise to this disorder. As they are not yet 
adopted in the books or confirmed by the researches 
of others, I shall venture here to restate briefly my 
views so as sufficiently to illustrate the peculiarities I 
have seen. 

Group First. — The common type; awkwardness and 
incoordination of voluntary movement, followed soon 
or late by automatic or unwilled clonic spasms of 
various parts. 

Group Second. — The disease never gets beyond the 
first stage of incoordination. Just as in some scle- 
roses of the cord there is no tremor save during voli- 
tional acts, so here the irregular motions only occur 
during willed actions. 

Group Third is, I think, the most unusual type, 
but I see occasional cases every spring. In this 
there are constant automatic, irregular, clonic spasms 
usually of the hands, but during volitional acts these 



CHOREA OF CHILDHOOD. 145 

entirely vanish, and the most complicated acts are 
well performed and without obvious incoordination. 
In other cases voluntary motion merely lessens the 
spasmodic activity, but does not abolish it. It is 
necessary to illustrate only this third group. 

T. C, set. 14, female, applied at my clinic in May, 
1879. She was a florid healthy looking descendant 
of healthy people, but had one brother who was epilep- 
tic. In March, 1878, she was attacked rather sud- 
denly with clonic spasms of both hands. These parts 
were in incessant movement during- the waking; hours, 
and until she attempted some acts of volition. Then, 
and during the movement in question, they were en- 
tirely free from all appearance of incoordination. She 
could write, sew, lift a glass of water, or do any other 
act involving complex motion without the least tre- 
mor, but in a moment after it was done, the fingers 
would again resume their spasmodic activity. 

I have seen a number of these cases. They are 
distinctly choreal, and yield to such treatment as is of 
value in that disease, but they differ plainly enough 
from the ordinary type of chorea. 



13 



146 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE VIII. 

HABIT CHOREA. 

I have over and over in my clinics called attention 
to a disorder of childhood which is the source of some 
anxiety and more annoyance both to parents and 
physicians. This trouble I venture here to label 
Habit Chorea, and for reasons which, I think, are 
good and which will appear in full as we consider the 
cases. 

Over and over some anxious mother will ask you 
to notice her child on account of some little trick or 
gesture in which the child indulges. Then you will 
see that it is winking rapidly, or pursing up the 
mouth or drawing it to one side, or, perhaps, that the 
brow is lifted at intervals or a shoulder shrugged, or 
some forward movement of the jaw or head is re- 
peated over and over at varying intervals. 

These acts occur usually in children of either sex, 
but I think most often in girls from 7 to 14 years of 
age. In many cases the single grimace or motion is 
repeated for months and then disappears, and, if this 
were all, I should hardly think it worth while to label 
so trivial a disturbance of -health ; but in other cases 
the first habit is lost by and by, and another takes its 
place, so that the variety and obstinacy of the habits 
become troublesome and even cause alarm ; or, worse 



HABIT CHOREA. 147 

still, the little patient lias a large repertory of these 
performances, and will execute a remarkable variety 
in one day. Usually, in such instances, there is some 
one motion which is more violent or more frequent 
than the others. 

If you examine with care the history of these little 
patieuts }^ou often find that there has been some 
fall from the plane of health, and you will at once 
wish to know wherein the child's life and work and 
play are not what they should be. Sometimes find- 
ing nothing to blame, you will recall the fact that, 
in the process of growth, children undergo cyclical 
changes which are not permanent, and which in turn 
may bring or take away tendencies to neurosal dis- 
orders, so that you must not always expect to be able 
to detect the causes of such disease. 

If you analyze more closely the character of the 
symptoms we are studying, you will find quite enough 
to repay attention. You will observe, first, that atten- 
tion to the child increases the trouble, and that any 
little failure in health has a like influence. Then, if 
you see many such cases, you will observe that these 
children are sometimes irritable or excitable, or ex- 
hibit clearly enough a condition of nervousness, being- 
more emotional than is natural ; while, in a few 
instances, they lapse into well-pronounced chorea of 
the ordinary type. In fact, this disorder has a cer- 
tain kinship to the latter affection. If you ask an 
intelligent child, who is thus diseased, why it makes 
the grimaces, or repeats, at intervals, some odd move- 
ment, you will learn that, while the patient is able, 
in most instances, to restrain itself and control the 



148 DISEASES OF THE NERVOUS SYSTEM. 

exhibition of motor disorder, tins restraining power 
becomes increasingly difficult the longer such effort 
lasts, and that a certain malaise or discomfort results ; 
while to give way and let the morbid impulse have 
full sway is attended with a sense of comfort and 
relief. 

Such is, in brief, a'll that I know about this small 
malady; although you will, perhaps, comprehend it 
better if I relate cases and point out, by illustrations, 
the fact that its treatment should be very much that 
which is needed in full-fledged chorea ; another argu- 
ment, if a slight one, in favor of the relationship of 
the two disorders. 

During the present month of November I saw M. 
C. Gr., oet. 13, girl. Never a robust child, at the age 
of six she became, without known cause, nervous, 
restless, and irritable ; and was, for awhile, a bad 
and uneasy sleeper. About this time she began to 
have a slight hacking cough, which came and went; 
was made worse by an attack of scarlet fever, and 
still exists at times. It sounded like a cough which 
was forced and voluntary. At nine or ten years, the 
cough almost passed away, and was succeeded by a 
sort of snuffling, during which she made the usual 
grimace, always on the left side, and precisely such 
a movement as accompanies snuffling. Whenever 
she makes this contortion she pushes her cheek up 
with the left hand. For a long while the cough and 
the snuffling act continued, the one or the other being 
prominent for a time. She was scolded and bribed 
into making great efforts to stop these morbid acts, 
and more or less succeeded. The next summer she 



ITABIT CHOREA. 149 

was taken to Saratoga, and the cough and snuffles 
abated, but a new symptom arose. The mouth would 
be opened wide, and as it closed both eyes shut, and 
remained closed for a moment, or else this took place 
without any opening of the mouth. 

When I saw the child, all of these odd movements 
were in full activity, but usually one of the three was 
more frequent than the others. There was at this 
time a good deal of dyspepsia, sluggish appetite, and 
pain in the back low clown, probably indicative of 
the coming on of her menstrual flows, the approach 
of which was rendered probable by a rapid develop- 
ment of her bust and pelvis. She had had no worms, 
and no organic or functional disturbances other than 
those I have mentioned. As she is just now, for the 
first time, under treatment, I can say nothing as yet 
of its success. Careful and good diet, light gymnas- 
tics, no school, gentle aperients, and full doses of ar- 
senic constitute such therapeutics as seemed to me 
reasonable. I ought to add, that she does not seem 
in any degree mortified at her own peculiarities, and 
this will be met by some effort to make the matter 
appear to her as rather disgraceful, and not to be 
mentioned — something, in fact, to be ashamed of. I 
shall be much surprised if this combination of physi- 
cal and moral treatment fails us. 

The next case I shall relate is quite as good a type. 
This was a lad, aged fourteen, who was taken from 
school a few months before on account of twitching 
and nervousness. He had become also irritable and 
capricious, and the grimaces, for which chiefly he was 
brought to me, had increased, and had, indeed, been 

13* 



150 DISEASES OF THE NERVOUS SYSTEM. 

increasing from the previous April, and until he gave 
up school late in July. It is in fact usually safe in 
such cases as this, and in all choreal troubles, to pre- 
dict either a return or an increase of the symptoms in 
the spring. 

In this lad the twitches began with snapping of the 
eyes, and this came and went, but was never quite 
lost, but merely lessened when some new symptom 
arose. The second form of trouble consisted in a 
curious rolling of the head, difficult to describe. This 
was bad enough, but quite suddenly within a few 
days the face became more quiet, and there arose a 
disorder of the abdominal muscles which Avere 
abruptly contracted at intervals. Over this and over 
all of these motions my patient had a good deal of 
control. If he set himself to hold it in check, this 
was possible so long as he steadily attended to the 
task, but while it was easy to repress it for fifteen 
minutes it was difficult after half an hour, and increas- 
ingly more and more hard, until by and by some 
slight lack of attention enabled the act to recur, or 
else the sense of discomfort and strain involved in 
these resolute acts of will power became unendurable, 
and the lad abandoned the effort. After a month or 
two of these movements, the respiration was broken 
every few minutes by a sudden long drawn abrupt 
inspiratory act. Still later the head w r as affected, 
or rather the neck, with a little short negative shake. 
The abdominal and respiratory disorder gave way at 
last to shrugging of one shoulder, and then to this 
with a queer upward pull of the whole side. The 
worst attack lasted but a few weeks, and was a sort of 



HABIT CHOREA. 151 

straightening up of the body. These varying condi- 
tions endured for several years. At one time the 
boy seemed well, then spring time or any little malady, 
especially indigestion, or much study and in-door life 
seemed to reproduce the troubles in some shape new 
or old. It was a slight grimace to-day, and in a 
week or two it was a sudden action of the muscles of 
the back or a shrug or a spasm of the muscles of the 
belly. In no case did the hands or feet suffer, and 
always the disorderly act was distinctly controllable 
by will ; this repression was unpleasant, and some 
relief was found in allowing the muscles to have their 

way. 

As the patient's eyes were plainly imperfect, Dr. 
Noyes, of New York, was so kind as to send me a 
statement to the effect that the lad had, in the right 
eye a slight mixed astigmatism, and in the left a 
slight compound hypermetropic astigmatism. These 
errors were really trifling in amount. Toe eye mus- 
cles showed some weakness. The eye grounds were 
healthy. 

I had a long bout of treatment with this lad, whose 
docility and good sense lent me every help. 

He took at first a good deal of valerianate of zinc, 
and had cold douches to the spine, and also arsenic 
internally. Meanwhile he was taken from school and 
set free in Yirginia on the sea-coast to ride, swim, 
shoot, and fish. Notwithstanding these wholesome 
aids, we got no further in the way of relief until we 
began to use hypodermic injections of arsenic. For 
this Fowler's solution without the lavender was used 
thrice a week, iu doses rising from two drops to twelve, 



152 DISEASES OF THE NERVOUS SYSTEM. 

and as this heroic medication was followed by rapid 
subsidence of the symptoms, it was continued for 
nearly three months. A sea-voyage and residence 
at an English school completed his cure, and then 
we had also the favoring influence of approaching 
puberty. 

These cases, and I might readily add others, suffi- 
ciently illustrate the varieties and the peculiarities of 
the disorder to which, for reasons which must now be 
plain enough, I have with some hesitation given the 
name of Habit Chorea. The last case also defines suf- 
ficiently well what the treatment ought to be. 



DISORDERS OF SLEEP. 153 



LECTURE IX. 

DISORDERS OF SLEEP IN NERVOUS OR 
HYSTERICAL PERSONS. 

The man before us is a feeble anaemic creature, 
who complains that he has become nervous, an ill 
sleeper, and has lost weight. He is a coffin maker, 
and looks as if he were artistically fitted for some 
such ghastly labor. He has no organic malady, and 
I only speak of him at all because one symptom of 
his case is of sufficient interest to serve as a text. 

He tells his story well, perhaps more dramatically 
than I can, but with less brevity than I need just now. 
When falling asleep he is conscious of something in- 
definable, not describable, rising from his feet and 
going up to the head. Usually he can move and thus 
check the progress of the disorder ; sometimes he can- 
not and then the attack results in a sense of some- 
thing like a blow struck on his head. At first it 
created terror, now he has become used to it, and is 
no longer alarmed, although the expectation of it is 
unpleasant, and apt to keep him awake. 

This is a mild form of a very curious symptom — -I 
can hardly call it more — which is quite common 
among hysterical women, more rare among men, and 
which exists in a variety of forms, and is in such 
persons at times a difficult symptom to deal with, and 



154 DISEASES OF THE NERVOUS SYSTEM. 

in certain cases the parent of a great deal of mischief. 
In 1875, I published a brief paper 1 on some of the 
disorders of sleep, in which I described these phe- 
nomena as follows : — ■ 

'The trouble I shall describe is rarely found alone, 
but makes a part of one of those groups of neurosal 
symptoms which have no place in the books, and 
which are apt to vary largely. 

1 M. A., a prominent physician from the Northern 
States, after a season of greatly excessive labor, be- 
came rapidly anasmic and weak, and developed the 
following symptoms : tingling, numbness, and heat of 
the extremities — now here, now there — on the chest, 
face, or scalp. At times, after much fatigue, islands 
of vasal paresis, seen as slightly raised purple blotches 
on the feet, are observed, and frequent waking up at 
night, with numbness of either arm ; feeble sleep, a 
dull, occipital pain, which made him wish to hold the 
part ; singing in the head, referred now to the occiput, 
now to the ears, but an inconstant symptom. He 
was at last driven to consult me by the following 
symptoms, which caused him the utmost alarm. 

' When just falling asleep, he became conscious of 
something like an aura passing up from his feet. 
When it reached his head, he felt what he described 
as an explosion. It was so violent and so loud, that 
for a time, he could not satisfy himself that he was 
not hurt. The sensation was that of a pistol shot, or 
as of a bursting of something, followed by a momen- 
tary sense of deadly fear. This sense of an aura is, as 
Brown -Sequard wisely says, not confined to epilepsy.' 

1 Virginia Med. Monthly, Feb. 1876. 



DISORDERS OF SLEEP. 155 

I have now in my care, a very accomplished gen- 
tleman, whose case is in almost every respect like that 
just sketched, except that the numbness is never uni- 
versal. The victim (Mr. V.) is, in this instance, a 
slight sensitive scholar, not overworked, but too 
steadily worked, which may amount to the same 
thing. In him, the numbness of the finger-ends came 
on abruptly, but as in the other case, there is no true 
loss of tactile sense, and possibly, nay probably, the 
feeling belongs to some condition of the lesser blood- 
vessels of the part, and only secondarily to the nerves. 

He feels, as he is falling asleep, a sense of something 
about to happen, but no distinct ascending aura. If 
he arouses himself in time, for which at the moment 
he clearly comprehends the need, he can by turning 
over relieve himself and break the chain of morbid 
events. He can even watch, as it were, the coming 
of the shock, and in some way know the moment be- 
yond which he must not wait. The first patient de- 
scribed as suffering in like fashion has also remarked 
on this peculiarity. Mr. V. has rarely the sense of a 
pistol-shot or a blow on the head. "I have,'' he says, 
11 at the close of the attack, a noise in my head, which 
is sometimes like the sound of a bell, which has been 
struck once, and I have in my case listened as to a 
bell, to the vibration coming and going at rhythmical 
intervals, or else I hear a loud noise, which is most 
like that of a guitar string, rudely struck, and which 
breaks with a twang." The result is always, how- 
ever, a sense of dread, but not such a death terror as 
has Mr. A. 

I have been told by other persons, that they were 



156 DISEASES OF THE NERVOUS SYSTEM. 

liable, when going to sleep, to have sudden sounds, 
faint usually, and rarely loud, but without feeling of 
terror. 

Since writing this account I have seen a large 
number of persons who suffer in like fashion from 
some one of the various forms. The most of the 
cases are women worn out, or tired out, and hysteri- 
cal, whether strong and well nourished or not. In 
sturdy men it is rare, unless they be excessive users 
of tobacco. 

The disorder in question I never saw in a man, ex- 
cept in the border land between waking and sleeping. 
He may have the aura and then the subjective sensory 
phenomenon, or the latter may come without warn- 
ing ; but in hysteric females these attacks may arise 
either at the moment of going to sleep, or during the 
day at any time, and while fully awake. At times 
they are slow in the march of their symptoms, and 
may be checked by the patient if, what is rare, she have 
enough of resolution ; but very often the aura rises 
fast, too fast to allow of action or of emotion, or else 
just slowly enough to give time for a sense of fear, the 
full development of which requires a certain amount 
of time. 

The warning by an aura is common in women thus 
attacked, and consists either in an indefinite sense of 
something rising towards the brain from the feet or 
hands, or both, or else it is a distinct tingling. 

In a smaller number of cases the only warning 
is an impending sensation of pure terror, which 
increases until the sensory shock occurs. But as 
regards all forms of the aura, or warning sensation, it 



DISORDERS OF SLEEP. 157 

is found tli at, as a rule, the intensity of the emotion 
weakens with repetition. 

The aura is totally lost in the phenomena which 
follow. These may be classified as follows: — 

1. In the sphere of general sensation: sense of a 
blow, of shock on or in the head, of rending or 
bursting. 

2. In the auditory sphere : loud noise like an ex- 
plosion. 

3. In the visual sphere : flash of light. 

4. In the olfactory sphere : sense of odor. 

5. A combination of two or more of these sensory 
manifestations. 

6. More or less abrupt and general motion, the 
ordinary outcome of any violent and sudden sensa- 
tion. 

It will repay us to analyze somewhat more minutely 
the pecularities of these interesting attacks, since I 
have usually found that they are not only sources of 
alarm to patients, but of doubt and puzzle to their 
medical attendants. 

In the first group the final symptom is referred to 
the head, and is a feeling of a blow, violent or light, 
struck on the skull ; or it is a feeling so terrible as 
to be described as something like an explosion, or a 
pistol shot, or more vaguely as a shock, something 
undefinable and terrifying. 

The auditory forms are described in their varieties 
as a noise, an explosion, the sound of a bell, a booming 
sound — that of a guitar-string rudely struck. 

The visual form is simply a flash of light, with or 
without sense of noise. 
14 



158 DISEASES OF THE NERVOUS SYSTEM. 

The single case of an olfactory form of sensation 
will be more fully described hereafter. 

The affections of general sensation may exist with 
auditory symptoms or not, since, when it is possible 
to get a patient to evolve, out of the terror and con- 
fusion of such attacks, an analysis, they usually men- 
tion some disturbance of audition as going with the 
sense of a blow. 

In rare cases the patient is left with a momentary 
vertigo ; more often the start which announces the 
sensory symptom ends the attack, so far as its imme- 
diate phenomena are concerned. Not so, however, its 
results in the emotional sphere. In some persons it. 
gives rise to great alarm, even after many repetitions 
of attacks, and in these and others is apt to leave the 
victim shaken and hysterical, or to be the first of a 
series of hysterical symptoms, the end or exact future 
of which no man can predict. 

I would like now to illustrate some of these inte- 
resting symptoms by cases, always asking you to re- 
member that in this lesson, as in some others, I am 
picking out a single symptom for study, and that it is 
not always the main feature of the case. 

The following case is told so well in the language 
of the sufferer that I prefer to leave her account al- 
most unaltered. It is one of a few rare examples in 
which the shocks occurred at times while awake as 
well as during the state of sleep. A series of severe 
mental and physical strains, and a slight sunstroke 
left my patient, a woman, now over fifty, anaemic 
and reduced to the weight of seventy-six pounds, 
her height being five feet three inches. Her eyes 



DISORDERS OF SLEEP. 159 

and ears were healthy, her womb normal. There was 
no trouble of any internal organ, but there was a loud 
soft haemic murmur at the right side of the base of the 
heart. Her sleep was good as a rule, but was easily 
disturbed and insecure. She writes thus : " Some years 
ago, when thirty -nine years old, after a long bout at 
nursing, sustained by quinine and stimulants, I began 
to fail in health, and then first became subject, whether 
asleep or awake, to a sensation, which I can only de- 
scribe as a wave going through my head and threaten- 
ing as it seemed to me an unconsciousness which 
never came. If in bed, I would start up, and if riding 
or walking would clutch at some near object for fear 
of falling, yet I cannot remember to have felt unstable. 
The following summer, after slight heat-stroke, and a 
new exposure to severe fatigue of body and mind, 
I experienced, once only, a sensation like the explo- 
sion of a pistol in my head. I hardly know how other- 
wise to describe it. A few months later, I began to 
have what I have always since called my shocks. A 
peculiar something, which for want of a better name 
I call electricity, starts from my head, chest, stomach, 
or bowels, and seems to pervade me in a flash, then 
comes the sense of shock in the head and an uncon- 
trollable shriek. At first, it never came unless mv 
eyes were shut, but for one week when I was most 
highly nervous and sleepless, it would come if I 
was startled by any sudden sound, and then I found 
that for a short period I could cause it by touching 
a spot over my stomach. 

" Of late, these shocks are not always preceded by 
any length of warning, and are in the head alone. 



160 DISEASES OF THE NERVOUS SYSTEM. 

They come mostly as I am going to sleep, and by 
straining my eyes to keep them open, I can some- 
times prevent the shocks altogether. I should say, 
that there is often some queer sense of chilliness 
in my head for an hour before the shocks, which 
is in a general way a warning of what may come. 
I do not like to so restrain them when the ten- 
dency is strong, as I then have one or two during 
the night while asleep, when they are very frightful 
to me. In some cases there will be a succession of 
weak shocks, and at last a strong one, when I shriek. 
After absence from home and freedom from cares, I 
have been exempt from these shocks for weeks or 
months." 

This unhappy case I mention first, because of its 
obstinacy. I have rarely seen the shocks thus per- 
sistent, and I am sure that they will disappear when- 
ever this woman becomes vigorous. Neither is the 
case quite typical, like one I have lately seen, and 
which readily got well. It is valuable because the 
shocks were so much the most prominent symptom. 

Early this winter, Mrs. L., of Massachusetts, aet. 45, 
a ruddy, hale looking woman, five feet four, weight 156 
pounds, came to me with this simple story: She was 
well until her husband met a year ago with disasters in 
business. Her anxiety about him, and the worry 
attendant upon the management of a household with 
suddenly lessened means, were made worse by the 
grave illness of her only child. She became nervous 
under these influences, and began to suffer from sounds 
which commonly cause no annoyance. Then her sleep 
got to be imperfect, and she had a series of hysterical 



DISORDERS OF SLEEP. 161 

attacks — the usual spasms — trismus, rigidity, hysteric 
coma, and the like, with a slight but distinct and 
general lessening of acuity of the sense of pain and 
of touch. Finally these phenomena passed away, and 
about this time she became subject to the shocks I 
have spoken of. These occurred either at the moment 
of going to sleep, and while quite conscious, or in the 
day-time, and when wide awake. 

The aura began in both feet, and ascended rapidly 
to the head, sometimes being felt also in the hands 
and arms. It was described as an air, and at times as 
a faint tingling. It ended in a sudden sense of a loud 
report, which caused her to seize her head with both 
hands, and left her in a state of alarm and feebleness, 
and with a brief but tumultuous throbbing of the 
heart. The attacks took place irregularly, once a week 
at first, and later at much longer intervals. Their 
effect was disastrous, because they gave rise to dis- 
tressing nervousness, and sometimes to prolonged hys- 
terical conditions, in which all her usual hyperaesthetic 
states were remarkably accentuated. 

While she was under my care I saw a lady from 
New York who was a sufferer from a variety of nervous 
symptoms, dependent in part on a split cervix uteri and 
a lacerated perineum. These were surgically relieved 
through operative means by Prof. Goodell, but the 
after-treatment of the hysterical conditions, hyperes- 
thesia, sleeplessness, and intense general nervousness 
was a slow process. The use of ether during the 
operation, which I have learned somewhat to dread in 
grave hysteria, seemed to be the immediate parent for 

14* 



162 DISEASES OF THE NERVOUS SYSTEM. 

a time of an increase in all her old symptoms, and of 
some new ones, among which were the shocks. 

The attacks came at any time except in sleep, and 
were similar to those of Mrs. L., but less severe. 
There was no aura, unless we can so call a feeling of 
impending peril, which lasted a few seconds, and 
ended in a sensation of a blow on the head. The 
attacks ceased after a month, and have never returned. 

The next case I have to relate was more curious. 
A girl, set. 18, was placed in mj care some years ago 
suffering from a slight unilateral hysterical paralysis, 
with well-marked anaesthesia. She was far less ner- 
vous than the woman I have described, and, in fact, 
it is, I think, not rare to find that women with distinct 
hystero-palsies are, if we omit ovarian tenderness, 
fairly free from the various hyperesthesia which 
constitute one of the groups of hysteric symptoms. 
She had, however, attacks when going to sleep, in 
which she became conscious of a something which 
seemed to ascend from the feet to the head. If she 
could rouse herself, or turn over, the attack termi- 
nated, and usually did not recur that night. It some- 
times happened, however, that she was not able to 
act in time, or was clearly conscious that she could 
not, in which case there was a wild flash of vivid 
red light, and she was at once seized with distressing 
nervousness, and sometimes with tremor. I do not 
remember that the attacks ever took place when 
awake, while it is as certain that they never occurred 
during sleep. 

The next illustration of the double sensory discharge 
giving rise to subjective feelings of sound and light is 



DISORDERS OF SLEEP. 163 

valuable, because the account is given to me by the 
sufferer, a medical officer of the United States Army, R. 
M. O'R, ret. 35, married, parents living, both of gouty 
diathesis. He is, and always has been, strictly tem- 
perate in all respects. Smokes in moderation. When 
twelve years old, had a sharp attack of intercostal 
rheumatism. In 1868 contracted malarial fever, from 
which he has suffered more or less ever since. In 
1867 received a trifling gunshot wound of right thigh. 
In 1875 had concussion of the brain, and some injury 
to back, resulting from a fall. Was confined to bed 
for a week or ten days, and walked with difficulty for 
some time after. Was troubled with vertigo for over 
a year. Has had no other sicknesses nor injuries. 

In June last, while sitting lost consciousness; did 
not fall. On recovering, saw objects surrounded by 
a halo; walked home with some difficulty, and went 
to bed ; slept none that night, but occasionally dozed, 
and was awakened by a sensation of falling, or by a 
sudden noise, or by voices calling. Eemained in this 
condition for about two days ; could arouse himself, 
but as soon as the effort relaxed, dozed, and had the 
feelings described. This condition gradually wore 
off, leaving vertigo, appreciable muscular weakness 
(especially of the lower extremities), a sense of con- 
striction around the head, wakefulness, and want of 
appetite. 

Late in June came to Philadelphia ; consulted Dr. 
Alison, who observed that one pupil was somewhat 
dilated. Subsequent ophthalmoscopic examination 
by Dr. Thomson showed nothing abnormal. 

Early in August went to Oswego, and has passed 



164 DISEASES OF THE NERVOUS SYSTEM. 

the time there and thereabout until a week ago. 
Within the past month has had two or three severe 
headaches, with pain, over the left temple. These have 
followed fatigue or excitement. 

At present he can walk but a short distance with- 
out growing very tired, then comes vertigo, seemingly 
confined to the posterior portion of the head, and a 
condition of nervous exhaustion, lasting some time. 
The same effects ensue upon mental strain of any 
kind. He sleeps fairly well. The feeling of constric- 
tion around the head is constant. Appetite variable, 
but never very good; bowels inclined to be costive; 
temper irritable; want of capacity to think a subject 
out, or to decide any question ; has lost weight. No 
organic trouble of heart, lungs, or kidneys. 

Since June last he has had several shocks, of an 
explosive character, which appeared to be within the 
cranium. They came at irregular intervals, and 
without assignable cause. They have always occurred 
just as he was falling asleep, and have been preceded 
by no abnormal sensations. He is awakened by what 
seems to be a loud explosion in his head, accompanied 
by a flash of white and blinding light. There is no 
pain with it, and except an acceleration of the pulse 
there are no sequeke. The noise thus heard is de- 
scribed as a rather low note, accompanied with a feel- 
ing as if the head was sundered by the explosion. 
The attacks come and go, but are always so dreaded 
as to make him dread the going to sleep. 

I have notes of a jet more singular case, which I 
hesitate a little, and perhaps without due cause, to class 
with these. 



DISORDERS OF SLEEP. 165 

A woman, set. 40, and in good health, was hurt 
during the tumult which followed the explosion of 
the boiler of a steamboat. She was thrown against 
the rail of the boat, striking her nose violently, and 
then fell into the water, whence she was rescued 
insensible. For several weeks she was very ill, and 
recovering became the victim of acute hysteria, which 
in a year passed away, leaving her feeble and emo- 
tional. Her sense of smell w r as entirely lost from the 
time of her accident, and except that she had at times 
a subjective and very annoying impression of the 
presence of an odor of brown soap, she had had 
absolutely no appreciation of odors. 

When I saw her two years after her accident she 
had, at long intervals, these symptoms. At any time, 
awake or asleep, she became aware of something like 
a touch moving over her, usually about the epigas- 
trium. After a few moments she experienced a sense 
of shock in the head, usually at the back of the head, 
and with it a remarkably distinct sense of a strong 
odor, like that of bananas. It persisted for, as she 
thought, a minute or more, and then slowly faded 
away. 

I have seen a number of these cases of sensory 
shock, and I suspect that, when inquired into, we shall 
find them less rare than might be supposed. The 
instances I have related cover most of the varieties I 
have seen, and it only remains to say a few words as 
to their clinical relationships, diagnosis, and treat- 
ment. 

The clinical relationships of these attacks are to 
epileptic fits, and to those well-known, and, I may 



166 DISEASES OF THE NERVOUS SYSTEM 

say, normal phenomena of a sudden movement of the 
body at the moment of going to sleep, or even at 
other times, to which I shall presently refer again. 

The analysis of the shock attacks is simple. The 
basis is hysterical excitability, or a hyperesthesia 
from tobacco, or overwork with worry. The at- 
tack itself is preceded in many cases by an aura of 
some kind, which is the first sensory expression of 
the coming disturbance. The aura is a phenomenon 
of general sensation. Then follows a more or less 
violent discharge from a centre of general sensation, 
as of a blow or shock ; or from auditory centres, a noise 
as of a bell, a guitar-twang, or an explosion ; or from 
visual centres, a flash of light; or, perhaps, two centres 
act at once ; and there may be no aura, as in many 
epilepsies. 

The fact that these attacks do in some people take 
place in the waking state, removes them from dream 
phenomena, and from the domain of nightmares and 
of night-terrors ; one form of which occurs in the inter- 
val between sleep and waking, and presents some 
analogies to these attacks of sense-shock. 

In this form of night-terror, which is seen rarely, 
but has often enough been described to me, the 
sufferer is perfectly conscious of the coming on of a 
nameless dread. Something precedes it in the way 
of a warning. He can, by an act of will, escape it by 
motion, or he may watch its onset. "When it cul- 
minates it is merely a state of insensate dread or 
terror, without a felt cause, dreamed or other. This 
seems to me, in the mental or mere emotional sphere, 
to be closely akin to the sensory shocks. 

As to diagnosis I do not see how these attacks can 



DISORDERS OF SLEEP. 1G7 

well be confused with anything else, unless with the 
minor epilepsy, from which it ought to be easily 
enough distinguished. 

As to treatment there is not much to say, but what 
there is to say is important and interesting. 

As we are dealing chiefly with the nervous mala- 
dies of women, the cases in which sensory shocks are 
caused by tobacco and excess of brain- work do not 
so immediately concern us here. I may, however, 
be permitted to say that in all symptoms directly 
traceable to tobacco there are two remedies available 
while the habit is being broken, strychnia and alco- 
holic stimulus. It should be needless to say that the 
man who orders the latter ought to have some secu- 
rity that his patient will not construe his orders too 
liberally. But this is a matter for a doctor's con- 
science ; and, at least, he may feel secure that a little 
whiskey at bedtime will correct the evil results of 
over-use of tobacco, and may be left off as soon as 
the tobacco is much lessened. As to strychnia no 
warning is needed ; and Dr. Landon B. Edwards has 
pointed out, and with reason, that it is the tonic most 
useful in the feebleness which comes of abuse of 
tobacco — that pleasant wife and fatal mistress. 

As to cases of sensory shock in women, the real 
remedy lies in treatment of the conditions out of which 
it grows. Of these, I have already said enough, but 
there is one matter as to which, in the nervous mala- 
dies of women, it is hardly possible to say enough. 

Perhaps I had better introduce what I wish to say 
in this direction by a brief extract of a letter from a 
woman who has suffered gravely from the shocks I 



168 DISEASES OF THE NERVOUS SYSTEM. 

have described. She sa}^s : " I suffer, as you are well 
aware, from these shocks in the time between sleep 
and wakefulness, and also in the day-time, though 
rarely then. It did not seem to me at first possible 
that I could in any way control these attacks or 
save myself from their results. I found, however, 
that, as I had warning enough, I really could do so. 
So I set myself every night to be resolute to turn 
over or sit up if I had a warning ; and every day I 
said to myself, if I have the warning to-day, I will 
not yield, but jump up and run about. To my sur- 
prise, I found that by following out this determina- 
tion with resoluteness I could break up most of the 
attacks." 

The treatment hinted at in this letter from a clever 
woman is really valuable. It consists in instructing 
the patient before going to sleep, and every day, to 
keep in mind the need to break the attack by motion 
and by an effort of will. 

I do not know of any drug which is directly useful 
in such cases of sensory shock as seem too grave to 
await in patience the influence of general tonics. 
The bromides are, in competent doses — such doses as 
make deeper sleep than common — dangerous to nutri- 
tion or at least hurtful enough to be avoided if pos- 
sible ; and in the small doses, in which they do good 
in hysteria, are, as regards this particular symp- 
tom, valueless. Small doses of chloral or morphia, 
used until the habit be broken, answer well ; but still 
better is a general improvement in health, and then, 
if the attacks persist, such exercise as will insure 
natural fatigue deep enough to make it impossible to 
avoid sleep. 



DISORDERS OF SLEEP. 169 

In the same paper on sleep to which I have already 
alluded occurs some brief account of the motor dis- 
charges which are so familiar to us all as taking place 
just at the moment of deepening sleep. 

What I pointed out then, and what I wish to recall 
attention to here, is that this normal symptom, if I 
may be allowed so to call it, does sometimes rise into 
the mischievous position of being the dominant diffi- 
culty in a case on account of its interference with 
sleep. 

The symptom in question — while it rarely takes 
place except in the interval between waking and 
sleep, and never between sleep and waking — may 
also arise during sleep itself, and cause abrupt dis- 
turbance. I have seen it very troublesome in. grow- 
ing lads and in some overworked men; but it is rare 
to find it so strikingly developed as in the case of a 
woman who consulted me to-day. This unfortunate 
person was forty-three, the mother of several children, 
and of late irregular in her menstruation. I was 
struck with the fact that her color was good, but that 
she was curiously thin and very haggard. She is 
well as to her digestion, but has too much wind, and 
finds eating hard work ; otherwise she is well in the 
day-time, and can read, sew, walk, or drive, as pleases 
her. Once or twice she has had long crying spells, 
without other cause than a sense of the wretchedness 
of her condition. When bedtime comes she goes 
with fear and reluctance to encounter sleep and the 
discomfort it brings to her. Just as she begins to 
lose herself, an arm, a leg, or the whole body sud- 
denly moves with violence. As she awakens, her 
15 



170 DISEASES OF THE NERVOUS SYSTEM. 

hands a ad feet, or either alone, twitch for a few 
moments. Then she settles herself to sleep anew, 
only to repeat the same process, until at last she sits 
up, crying hysterically, or, worn out, falls into a 
slumber seemingly too sudden and profound to allow 
of the phenomena I have described. Her daughter, 
who came with her, described these nights of suffer- 
ing as truly pitiable, and told me that nothing had as 
yet seemed to afford the least relief. 

Of late, Mrs. K. J. has been apt to wake up later 
in the night with unilateral tingling, of Avhich I shall 
presently speak more fully. 

You must of course consider this as an unusual 
case ; but it is just unusual cases which are apt to 
puzzle young physicians; and to be able in such cases 
as these to recognize the close kinship between an 
almost natural phenomenon and its excessive develop- 
ment into an annoying disorder, is not only comforting 
to the patient but useful to the physician. 

A good many hysterical women exhibit this symp- 
tom ; and in a few it becomes troublesome, either by 
its repetitions, as in Mrs. E.'s case, or, what is less com- 
mon, from its severity. A quite ludicrous example 
of the latter I saw a few years ago. The patient was 
one of those stout, ruddy women, with good ovaries, 
and uterus where it should be, and yet hysterical to an 
exasperating degree. She weighed over 200 pounds, 
and was unhappily subject to what she called "fish- 
flaps," which were really remarkable, because her 
body would be thrown up from the bed so high, and 
descend with such violence owing to her weight, that 
it was not rare to find the slats of the bed giving 



DISORDERS OF SLEEP. 171 

way. She grew better as her hysteria lessened, but 
is, I believe, still subject at times to these unpleasant 
and undesired gymnastic symptoms. 

There is yet another and a very interesting sleep 
symptom seen at times in Duchenne's disease, and 
in a variety of degrees in some feeble and anasmic 
persons ; but far more common among women than 
among men. I ventured some years ago, in speaking 
of it, to call it "night palsy," or "nocturnal hemiple- 
gia." Since seeing more examples I perceive that 
brachial monoplegia is its most common expression. 

This curious symptom assumes one of two forms — ■ 
the one common, the other rare. In the more usual 
cases the sleeper awakens with numbness, or rather 
tingling and numbness, of one arm, a leg alone, which 
is infrequent, or the whole side, including the face, 
and even the tongue, which is now and then attacked 
alone. The disorder may be mere tingling, or actual 
loss, or rather lessening of tactile sensation ; but in 
any case it rapidly fades away, or yields to a little 
friction. At first, while it is in the arm alone, the 
patient refers it to lying on the part ; but this be- 
comes an impossible explanation of the hemiplegic 
examples. 

As I have seen in a month three cases of this 
rather interesting condition, it cannot be very rare. 
It is significant, perhaps, that some persons who have 
gotten pretty well of a hemiplegia of organic cause 
are liable to awaken out of sleep with numbness and 
lessened power of the side once palsied. It is remark- 
able that in the case of Mrs. E. J., of which I just now 
spoke, this same curious functional hemiplegia would 



172 DISEASES OF THE NERVOUS SYSTEM. 

at times occur on the same nights when she suffered 
from motor discharges. 

The less common form of night palsy is, perhaps, 
also the more serious, but may be like the usual 
examples, but an expression of hysteria or of the 
exhaustion felt by an ill-nourished brain during the 
long fast of the sleeping hours. In it the patient 
exhibits a far more distinct loss of unilateral power, 
which, however, lasts for an hour or more after 
awaking, and may even become worse for a time in 
place of at once improving. 

I recall very well the case of Mrs. C. L., set. 27, 
who, after profound blood losses in confinement, 
nursed, with success, through several excessive men- 
strual periods. She then had an attack of nocturnal 
hemiplegia, which became more grave during some 
hours, and yielded easily to faradic stimulation, iron, 
and good diet. She had after this several light 
attacks, and twice well-marked brachial diplegia, 
which lasted but a few hours. I should add, that 
there was no renal trouble, and that she made a 
perfect recovery. 

Among other milder forms of trouble, which at 
times haunt the sleep of nervous or hysterical females, 
are palpitation of the heart, vertigo, and a certain 
failure of the respiratory centres, which is met with 
also in grave shape in some cases of Duchenne's dis- 
ease, or in any very feeble people, and is, of course, not 
confined to women. 

In locomotor ataxia, towards its paralytic stage, 
this symptom is but an expression of a defect in the 
medulla oblongata, and has twice in my knowledge 



DISORDERS OF SLEEP. 173 

finally resulted in sudden death during sleep. In 
feeble and hysterical people it means simply a tem- 
porary failure of function, owing to imperfect nutri- 
tion. 

The centre remains competent so long as the will 
is free, during the waking hours, to assist the auto- 
matic activity of the ganglia, but when sleep leaves 
the regular succession of respiratory acts to the 
unaided powers of defective nerve-cells, there some- 
times comes a moment of temporary incompetence, 
and the patient wakes up gasping and alarmed. 

The best remedy for these troubles is to be found 
in the general treatment, of which I have already 
said enough, and in great care to supply nourishment 
at bedtime, and if needful to repeat its use during 
the night. Of course I take it for granted that every 
care shall have been given to the state of the stomach 
and bowels ; and I may add, finally, that some patients 
suffer less, or not at all, if lying on one side or the 
other, or on the back, the position of success being 
purely a matter of experiment. 



15* 



174 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE X. 

VASO-MOTOR AND RESPIRATORY DISORDERS IN 
THE NERVOUS OR HYSTERICAL. 

I have over and over called attention in my clinics 
to some of the many and curious vaso-motor disturb- 
ances which we see in so great variety among nervous 
women. From the heart to the capillaries we are 
liable to meet with conditions of disorder, which are 
sometimes almost as lasting as if they owed their 
parentage to obvious and coarse structural lesions. 
This indeed is a familiar fact which I have had ample 
opportunity to verify both in my clinic and in my pri- 
vate practice. No matter what be the form of gene- 
ral nervousness or the variety of hysterical illustra- 
tion, the nervous supply of the heart or vessels, or 
both, almost never escapes from bearing some part 
of the mischief, and only too often, after everything 
else is well and the patient is afoot and able to live as 
pleases her, she will still be reminded by something 
in connection with the blood supply and its channels, 
that they are almost the last to regain the vigor and 
steadiness of health. 

The first point to which I wish to ask your atten- 
tion is the pulse. In the mass of hysterical women, 
and especially in those we see here who are apt to be 
feeble, and easily tired as well as liable to tears and to 



VASO-MOTOR DISORDERS. 175 

more distinct expressions of the hysteric temperament, 
the pulse is apt to be permanently rapid, that is for 
months or years it may remain 20, 30, 50 pulsations 
to the minute above the normal number. You may 
see this in a woman who is supine in bed, and who 
for the time presents no startling evidence of general 
disorder. I shall have presently to illustrate this fact 
by cases. 

But besides the speed of the heart movement these 
cases present also two other phenomena ; their hearts 
are irritable and prone to beat rapidly owing to causes 
which are powerless to affect the less excitable organ 
of the healthy. Then also with this cause of being 
set going beyond their common rate these hearts 
are apt to become irregular, and to seem to tumble 
about in an alarming manner. The careful study 
of these well-known peculiarities will very well 
repay us. Therefore, before going further we will 
linger a little upon the questions connected with 
the pulse rate and rhythm of nervous or hysteric 
Avomen. 

Out of half a dozen good cases I take two or three 
to enable me to illustrate these points. After that I 
shall point out some of the eccentric pulse symptoms, 
and then say a few words as to the mode of dealing 
with the irritable heart of the nervous, either when it 
is but a symptom, or when it rises into such promi- 
nence as to be the dominant mischief. 

There was last -year in the Infirmary for Nervous 
Diseases, a lady from Yirginia, who presented in a 
typical form the cardiac states which I expect to find 
in neurasthenic women, and especially in such as are 



176 DISEASES OF THE NERVOUS SYSTEM. 

both feeble and hysterical. She was 38 years old, 
married but childless, and had been for some years 
subject to hysterical attacks, which passing away left 
her at last so feeble that she was unable to walk up 
stairs without great exhaustion. She was five feet 
one, weighed one hundred pounds, and was anaemic 
and sallow. Her uterine functions were fairly good, 
and she suffered no pain and had no distinct uterine 
disease although both ovarian regions were tender, 
and pressure upon them caused nausea and vertigo, 
as well as other phenomena to which I shall presently 
refer. Her digestion was good if she ate but little at 
a time and was not tired or excited. 

Her heart when she was lying down was never 
under 180 beats per minute. Any exertion raised it 
20 to 30 pulsations. The least excitement did the 
same, but despite this irritability the rhythm was al- 
ways good, and I should add there was no affection of 
the eyes or the thyroid gland. Pressure on the ovarian 
region gave rise to sudden increase in the number of 
heart beats, but pressure on the spine almost anywhere 
had a like influence. She had tried absolute rest for 
a week or two at a time, and had taken a large amount 
of tonics and of digitalis. Her temperature was curi- 
ous, being in the mornings 97-97.5°, and in the late 
evening, 9 to 10 P. M., 100-101.5°, although there 
was no pulmonary or other visceral trouble. The 
evening pulse was usually a few beats under that of 
the morning. 

Electricity (induced current, slow interruptions) 
used as a muscular exerciser, and also massage, ex- 
cited her greatly, causing tremor, tearfulness, and a 



VASO-MOTOR DISORDERS. 177 

rapid increase in the pulse. Withal, the heart was 
perfectly healthy as to its valves and its size. 

I began her treatment by using various forms of 
digitalis, but although she took enormous dosesl never 
succeeded in making any impression on the heart and 
usually this drug seriously disturbed digestion. I found 
that frequent small feeding with rest somewhat aided 
her, but although she was thus made more comfort- 
able there was no substantial gain, until in despair I 
resorted to Carell's skimmed-milk treatment. After 
three weeks of this I was able to repeat the use of 
massage which I had been forced to abandon. From 
this time the improvement in flesh, color, and self-con- 
trol was notable. When she was able to walk about 
after two months of rest, the heart had fallen to 95° and 
was far less excitable, and her temperature ha'd be- 
come normal. It required, however, many months of 
care to make her circulation quite natural, but within 
six months she became fat (one hundred and thirty 
pounds), and was able to complete her cure by a sum- 
mer in the mountains. 

This was, of course, an extreme case of cardiac 
nervousness, but it is no unfair type, and I need add 
little to the description. Sometimes the tumultuous 
action of the hysterical heart is the most distressing 
and most upsetting of all the many symptoms of this 
disorder, so very fertile in symptoms. We all know 
how unpleasant and appalling even is the sense of 
sudden and great irregular palpitation, and in the ner- 
vous and hysteric this impression loses nothing of its 
terror. You will meet with such women — women 
whose hearts seem to become wildly irregular on the 



178 DISEASES OF THE NERVOUS SYSTEM. 

least provocation, or on none. Digestion in these 
women causes it, and here I cannot too earnestly insist 
that digestion, like some other functional acts, gives 
rise to symptoms which are not of necessity proofs 
that the function in question is imperfect or diseased. 
Ordinarily, if we have palpitation of a healthy heart 
during digestion, that means often enough that our 
patient is dyspeptic, but not so in nervous and hysteri- 
cal women. Digestion naturally quickens the pulse, 
and in these people the normal quickening passes into 
palpitation. That I am correct as to this is shown in 
the same women more rarely by the varied disturb- 
ances which follow the most perfect performance of 
other normal functional acts as simple as micturition 
or defecation. I have seen patients in whom bowel 
movement always produced irregular heart action, 
and I have now a lady under my care who has, soon 
after passing water, slight chilliness, twitching of the 
face, and extreme palpitation of the heart. Yet, the 
act of urination is, in this case, painless, and, in fact, 
absolutely natural. You may regard all of this as 
of trifling: moment, but I have seen cases like these 
treated with many drugs, and in a case similar to the 
last one I have known a surgeon resort to dilatation 
of the urethra. Bear in mind, therefore, that some- 
times in nervous people the activity of a normal func- 
tion is competent to cause distress or awaken symp- 
toms. 

The violence and singularity of the pulse-signs in 
true hysteria are beyond expression strange. 

I saw, very many years ago, a handsome girl, of 
twenty, from Cincinnati, who had spells of apparent 



VASO-MOTOR DISORDERS. 179 

death, if I may use such a term. One of these I had 
the good fortune to see, and indeed to cause, for hav- 
ing been warned by no one that, to speak before her 
of certain things, was apt to cause the trouble, I 
unluckily began to discuss with her the subject of a 
personal peculiarity, from which I had been told she 
suffered. 

It seemed that certain odors would, in her, bring 
on hysterical attacks. You may recall a case here, 
last week, of an aphonic girl, in whom musk would 
do this. Now my patient had, at last, become very 
sensitive as to this as to other matters, and no one 
near her ventured to talk about odors ; since then it 
seemed that the young lady was liable to suffer, as if 
from the odors themselves. Of late the hystero -epi- 
lepsy had given place to the "Death spells," as her 
friends called them, and it was one of these I pro- 
voked. She said to me, "I am going to have an 
attack ; feel my pulse. In a few minutes I shall be 
dead." Her pulse, which just before was about 100, 
was now racing, and quite countless; while the 
irregularity and violence of the heart's action seemed 
to me inconceivable. With the interest of an hys- 
terical woman in her own performances, she said to 
me, "Now watch it; you will be amazed." This cer- 
tainly was the case. Within a few minutes the pulse 
began to fall in number, and, as well as I can recall 
it, in some fifteen minutes was beating only 40. Then 
a beat would drop out here and there; the pulse 
meanwhile growing feebler, until at last I could nei- 
ther feel it, nor yet hear the heart. In this state of 
seeming death, white, still, without breathing or per- 



180 DISEASES OF THE NERVOUS SYSTEM. 

ceptible circulation, this girl lay for from two to four 
days. In this time there were spells of a few minutes, 
during which the heart beat again furiously and 
irregularly, as was also the case when she revived. 

Of course, emotion of any kind is, in such women, 
able to disturb the heart-rhythm and its number; 
and while such persons are subjected to the contacts 
of daily life, it is, therefore, hard to relieve them. 

The oddities of hysterical cases are perceptible 
enough in the way in which the heart -action seems, 
at times, to disobey all apparent laws, and baffle all 
predictive skill. I have seen such persons, whose 
hearts beat slower when they rose, and faster when 
they were lying down. I have now a patient, whose 
heart is quiet enough while she is supine, but to lie on 
either side causes palpitation and increased rapidity 
of pulse. 

There are now in the Infirmary two cases of great 
general nervousness with hysterical histories. Nei- 
ther has organic disease. The one has an average 
morning pulse of 100, and a night pulse of 75. The 
other nearly reverses these numbers, but I have been 
utterly unable to find a precise cause for these pecu- 
liarities. 

Apart from cardiac troubles, or in relation with 
them, are certain vaso-motor disturbances which give 
rise to very distressing, or, at least, to annoying 
troubles in this class of sufferers. 

Every hysterical woman is liable to a certain want 
of tone in the surface-vessels which gives rise to a 
group of disorders, owing to which we meet with 
extreme states of pallor or of flushing which in some 



VASO-MOTOR DISORDERS. 181 

cases affect the extremities and in others are most 
visible in the face. This want of steadiness in the 
vessels of the skin belongs to some extent, and natu- 
rally, to others than the class I speak of, and is seen 
very well in certain healthy women of fair com- 
plexion, and is also common in persons who are 
liable to the congestive type of neuralgic headaches. 
Watch one of these women, and, if they have this 
peculiarity in a high degree, it will come out under 
the excitement and embarrassment of clinical ques- 
tioning. You will then see the face flush, and the 
flush by degrees break up into spots of red which 
move slowly and have bounding margins of pale- 
ness; and all this will be best seen on the neck 
and cheeks and below the ears. At the same time 
the hands and feet /may become cold, and, at all 
events, you will find that almost incurably cold feet 
are the constant annoyance of these patients; and 
sometimes the cold feet are pale ; and sometimes, in 
graver hysterical cases with palsy or sensory defects, 
they may be purplish ; and both appearances indicate, 
as you know, defects of blood-supply, and both lead 
to like results. 

Another and very remarkable indication of the ac- 
quired sensitiveness of the surface-vessels in cases of 
the hemiplegia of hysteria is the well-known fact that 
any moderate traumatic injury to the skin-vessels gives 
rise to their instant contraction, so that slight wounds 
which usually bleed do not do so in them. I have seen 
this state of things in hysterical girls who were not suf- 
fering from analgesia, but in most cases it is found 
over a half of the body affected by some loss or lack 
16 



182 DISEASES OF THE NERVOUS SYSTEM. 

of feeling of some kind. As the feeling improves, the 
needle wound bleeds, and whatever aids the one con- 
dition helps the other, so that, when from the use of 
metals the phenomenon of transference of the anaes- 
thesia to the opposite limb occurs, it is at once found 
that needle wounds cease to bleed on the side attacked 
and bleed on that deserted by the disease. As I said 
in a former lecture, I have myself been unfortunate 
in never yet having been able to see the phenomenon 
of transfer. I have several times seen metals laid on 
the anaesthetic parts give rise to some partial return 
of feeling and of bleeding from needle-pricks, but I 
have seen caoutchouc and wood and even sponge do 
the same ; and the effect of a blister and of the rhigo- 
lene spray can be seen in a patient now in the wards. 
I may add that dry cups and mustard have also given 
me the same results. There may be indeed some 
unsuspected relation between loss of sensation and the 
bloodlessness of slight wounds, for in one, at least, of 
those remarkable cases of total surface anaesthesia to 
all forms of sensory impression, in a case of profound 
melancholia, although the loss of feeling extended to 
the face and mouth, and was certainly not hysterical, 
the surface was made to bleed with the most extreme 
difficulty. The same phenomenon of failure of pin 
pricks to bleed has been recently observed by me in 
a man with he mi- anaesthesia of cerebral and organic 
cause. It seems likely that cutaneous ischaemia is to 
be added to the list of symptoms which Charcot has 
pointed out as common to hysteric hemi-palsies, with 
loss of pain-sense, and the hemi-anaesthesia of more 
definite cause. Since I was led to suspect that there 



VASO-MOTOR DISORDERS. 183 

is some link of relation between anaesthesia and sur- 
face failure to bleed, I have been on the lookout for 
a case of nerve section in which to test the matter. 
Two days ago, Dr. E. J. Levis cut the sciatic and 
crural nerves in a man who has a deep and incurable 
ulcer of the left leg. This operation deprived him 
of all sense below the middle calf, and I was enabled, 
with Dr. Levis's permission, to examine, the case in 
his ward at the Pennsylvania Hospital. 

All forms of sensation were extinct in the foot. 
Using a very large needle, I left it in place some 
time, or turned it about freely, but was unable to 
cause a single drop of blood to flow from these re- 
peated wounds. As I withdrew the needle, a small, 
snow-white ring, slightly raised, formed around the ori- 
fice, and seemed to be due to contraction of the neigh- 
boring skin muscles. This most interesting observa- 
tion confirmed for me what already I had seen some 
years ago in other and less extensive nerve sections. 
I had, however, continued to doubt the correctness of 
the former observations, which were made in cases 
of division of ulnar or median trunks. It certainly 
seems as though the loss or lessening of sensation 
were associated with the taking off from the skin 
vessels of some inhibitory influence, so as to leave 
them to contract with violence under the influence of 
any irritating cause. All explanations may admit of 
question, but as to the fact to be explained, I think 
there can be no further doubt. I hope that I have 
here said enough to direct attention anew to this in- 
teresting phenomenon. 

Temporary flushing or pallor of face is very apt to 



184: DISEASES OF THE NERVOUS SYSTEM. 

accompany sudden and irregular heart action, and to 
become and remain a distressing symptom. Why, 
with a perturbed heart, this woman should have a 
deadly paleness, and that a profound flush of face, I 
cannot say, but both sets of conditions are familiar to 
me. Now, as in such females the heart becomes 
agitated, and the face red or white on the least pro- 
vocation, or on the mere expectation of it, you can 
readily see what an annoyance it may become. 

I saw last year a bright, intelligent New England 
girl, who, with much general nervousness, had also a 
heart far too rapid, but besides its speed, if she met 
a friend suddenly, or went into a drawing room, or 
was even spoken to unexpectedly, her heart became 
irregular, and her face very pale. You may readily 
imagine to how much misconception such a disorder 
might give rise. The longer it lasted the worse it 
became, and one pleasure or one duty after another 
was given up in turn, because of the shame to which 
every mildest emotion subjected her. After long 
treatment she became well as to most of her ailments, 
but had been a year in seeming health before her cir- 
culation re- acquired the proper tone, and she could 
again face, without fear, all the trials of social life. 

Flushing with tumultuous heart action is more 
common, and is, I should say, more like an exaggera- 
tion of a common functional event of health. Still, 
Avhen it occurs habitually on the least emotion, it 
is, like any such symptom, a source of most bitter 
annoyance. 

Unilateral, or strictly local flushing, is, I suspect, a 
very rare affection, either in hysteria or elsewhere, 



VASO-MOTOR DISORDERS. 185 

but, of course, the best examples are to be found in 
hysteria. 

Last year I was consulted by a lady, both of whose 
legs were as red as blood in excess could make them, 
and this state came on after many months of varied 
hysteric troubles. Excepting an imperfect paraplegia 
these had all passed away for the most part, but when- 
ever she sat up, her legs filled with blood and looked 
as if they might burst. Unlike cases of erythro- 
melalgia there was no pain, and when the limbs were 
elevated they slowly got back their color. Pin pricks 
bled easily, and there was no loss of feeling. I 
watched this singular condition for some weeks, every 
effort failing to relieve it, and finally, I may add, when 
it was let alone, and only the constitutional state was 
looked after, the local paralysis of vessels gradually 
got well. 

I have over and over seen this vasal paresis in the 
hands of these women, and one distressing case of in- 
tense and permanent redness of the face, which took 
at first a unilateral form, and then attacked the entire 
face in spells. These began at any time, but chiefly 
in the morning hours. A spot of color came any- 
where on the face, went and came, and at last others 
appeared. These coalesced after a time, and the color 
darkening the face, scalp, ears, and upper neck seemed 
like those of a heavy drinker. There was no pain, 
or only a sense of uncomfortable fulness and heat. 
The eye-ground did not seem to share so fully in the 
vascular fulness, but the depths of the ears did. Be- 
lief was obtained by a spray of cool water, which did 
b3st at a temperature of 50° to 60° F. If let alone 

16* 



186 DISEASES OF THE NERVOUS SYSTEM. 

the redness passed away slowly within three hours. 
At first, and at times afterwards, the heart's action 
was disturbed a little. I should add that very pro- 
longed use of digitaline seemed, with care of the 
general health, to do the most towards the complete 
relief of this unhappy patient. 

The last case of hysterical vaso- motor manifesta- 
tions which I shall quote was so amazing that if I had 
not had the good fortune to see it over and over, and 
to show it once to my friend Dr. William V. Keating, 
I might reasonably have hesitated to tax the credu- 
lity of my hearers. 

Some twenty years ago I attended a young married 
woman, whose life was embittered by losses of pro- 
perty, and by the ill-treatment of her husband, who 
finally deserted her. For a long period she exhibited 
at times hysteric disorders in the forms of spasms, 
rigors, hemi-palsies, and at last for a month or two 
moderate maniacal excitement. With favoring cir- 
cumstances she at last got well, and removing to the 
west, was lost sight of until about ten years ago, 
when I was called to see her at a hotel in Phila- 
delphia. At this time my patient was 35 years old, 
was irregular as to her monthly flow, and had, as I 
found, a womb tilted forward but not diseased, and no 
ovarian tenderness, or at least no teuderness of belly 
which was not the same everywhere. She was rather 
pale, and very thin, and had a relaxed pendent belly 
marked bj^ the scars of four pregnancies. I could 
find no disease of heart, lungs, or kidney. She gave 
me this brief history : After some years of ease and 
comfort, she had been led to risk her property in 



VASO-MOTOR DISORDERS. 187 

a wild speculation which ruined her, and now she 
was keeping a boarding house in New York, and was 
doing well, or likely to do well, except for the strange 
malady on account of which she came to consult me. 
After her new misfortunes she had some hysterical 
troubles, but these ceased to annoy her, and she began 
to observe that at or about the time of her menstrual 
flow, and afterwards at any time, she was liable to have 
an enlargement of the belly, which did not seem to 
her to be due to wind, as with that form of swelling 
her previous experience had made her but too fully 
acquainted. The trouble became by degrees worse, 
and at last was so extreme as to cause certain unpleas- 
ant feelings, and to subject her to suspicions of being 
pregnant. 

The swelling was certainly caused at times by emo- 
tion. It began at any time, rarely at night. Within 
a few hours the belly, in place of being flaccid and 
pendent, was swollen enormously. She looked, in fact, 
as a woman, thin as she was, would have looked at 
the eighth month of pregnancy. Other attacks were 
less severe, but always they lasted for some hours be- 
fore she could stand up, and it was usually a week 
before she was well. 

When I saw her an attack was at its worst. The 
woman's pulse was about 165, and was a mere thread 
at times imperceptible. Her face and limbs were 
white and cold. The abdomen was tense and red, 
and could be felt to throb distinctly, while all over it 
the vessels, veins, and arteries were visibly enlarged. 
On listening over the belly I could hear a humming 
noise, a slight thrill. The chest itself was not quite 



188 DISEASES OF THE NERVOUS SYSTEM. 

so pale as the neck or face, but the breath was diffi- 
cult and rapid. It was clear that owing to palsy of 
all the abdominal vessels, all the available blood of 
the body of a too bloodless woman was for a time in 
this cavity and its walls. If while in this state she 
sat up she instantly fainted, and it was difficult even 
to lift her head, because of the symptoms thus caused. 
She herself complained of the tension of the belly, 
and of the distressing pulsation within it. 

The day after the abdomen was certainly a third 
less, and it was then seen by Dr. Keating, who, like 
myself, could give no other explanation of the con- 
dition seen, than the one I have just mentioned. 
After a week the belly became nearly as flat as usual, 
and I then ceased to see my patient. I learned from 
her some years later that by slow degrees she had 
become well of this singular malady. 

Yet a few words before I abandon this subject as 
to the irregularities of breathing in the hysterical. 
These may accompany cardiac disturbances, which 
is rare, or may exist alone, without elevation or 
altered rhythm of pulse. In other forms of disease, 
as you well know, when the breathing becomes rapid, 
the pulse also proportionally increases in number; 
and it is uncommon to see excitement of heart from 
fever or inflammation without a like rise in the rate 
of respiration ; but hysteria breaks all laws, except its 
own rules of eccentricity. 

I have seen a woman -with a respiratory rate of 
10, and a pulse of 100 ; another, with a pulse of 30, 
and a normal speed of breathing. 

There is now in this hospital a case of hemi-anses- 



VASO-MOTOR DISORDERS. 189 

thesia and hemiplegia, getting well after two years 
in bed. When she began to walk abont, two months 
ago, her pulse was 60 to 70 ; her respiration 15 to 
18. My assistant soon after observed that the rate 
of breathing was increasing, and, without calling 
attention to it, we began to keep daily notes of it, 
and of the heart and temperature. 

The average pulse, early in November, was 75-85 in 
the morning and evening respectively. Eespiration 
16-17. 

At the close of December the pulse had slowly risen 
to an average, for the two daily observations, of 94.1, 
with, nearly always, a rather faster pulse in the 
mornings ; but, meanwhile, the breathing rose to a 
daily average of 49.4. 

Some of the numbers are remarkable. I give in 
a brief column one week, for comparison with 
healthy states : — 







Pulse. 


Respiration. 


Fulse. 


Respiration, 






Morning. 


Morning. 


Evening. 


Evening. 






10 A. M. 


10 A. M. 


10 P.M. 


10 P. M. 


Dec. 


22. 


102 


50 


91 


48 


it 


23. 


100 


52 


99 


53 


t< 


24. 


98 


57 


100 


62 


t( 


25. 


90 


55 


87 


47 


<< 


26. 


95 


37 


85 


39 


(( 


27. 


98 


55 


88 


44 


(( 


28. 


93 


49 


88 


89 



Mean 99.3 50.7 91.1 47.2 

The respiration was singularly tranquil, despite its 
rapidity, and there was not the slightest appearance 
of effort. Digitalis, given in half-ounces of the infu- 
sion, seemed to have no effect on the pulse after some 



190 DISEASES OF THE NERVOUS SYSTEM. 

days, but so disturbed the stomach that I was forced 
to give it up. The thirtieth of a grain of sulphate of 
morphia brought down the breathing one-fourth, and 
the one-twentieth of a grain had a still more percepti- 
ble effect, so that the average fell for the last week to 
28.1, while the pulse held an average of 81.2. A 
single full dose of opium, given to relieve pain, 
brought the respiratory rate from 58 to 17 within 
a few hours ; the pulse falling at the same time from 
88 to 73. 

This is a remarkable example of a rather unusual, 
but sometimes overlooked hysterical symptom. In 
a doubtful case it alone would decide the diagnosis ; 
for a like condition, outside of hysteria, is a clinical 
curiosity. The most remarkable illustration, not hys- 
terical, is that reported by Dr. J. H. Brinton and my- 
self. A man, after receiving a ball through his right 
lung, continued for years to breathe at the rate of 100 
to 130 to the minute ; his pulse being 85 to 90. 

I said that this abnormal rate might alone decide 
your belief in its hysterical cause ; nor is this a 
mere theoretical idea. A few years ago I was one 
of three physicians called to see a lady, long ill with 
a variety of ailments. She had passed into a state of 
stupor, from which, for two days, it had been impos- 
sible to arouse her. I observed that while her pulse 
was about 90, her breathing was almost impercepti- 
ble ; on careful count, however, it proved to be 96 in 
the minute, from which I was sure that the case would 
prove, in the end, to be hysterical; an opinion justi- 
fied within a few hours by the repeated occurrence of 
very violent hystero-epilepsy. 



HYSTERICAL APHONIA. 19 L 



LECTURE XL 

HYSTERICAL APHONIA. 

The patient before us to-day is a very notable illus- 
tration of the pranks which may be played by hys- 
teria. I read you her history, and as you hear it I 
think you will see that almost at any time a resolute 
man, whom she trusted and who understood her dis- 
order, could have saved her and her family from long 
years of suffering. Her case will enable me to point 
out to you, as I have done very often before, that the 
natural history of many of the forms of hysteria is 
still an open study. One reason for that is I pre- 
sume the disgust with which the general practitioner 
encounters this malady. It is hysteria, and with that 
seems to end all need for observation of details and 
varieties of symptoms, such as more manageable dis- 
orders obtain. 

Mrs. E., a3t. 31, from New Jersey, was brought up 
among people of narrow means and larger wants. A 
rather frail constitution and nervous parents doubly 
prepared her for the ills which were, perhaps, only 
hastened by an attack of ague, followed by pneumo- 
nia, in September, 1870. Soon after recovery a day 
of fatigue and some worries ended in hysterics, with 
retention of urine. A more violent fit followed an 
attempt to do some rather hard work. From this 
time the Pandora's box of hysteric ills was opened, 



192 DISEASES OF THE NERVOUS SYSTEM. 

and they came almost without limit. Remaining in 
bed, fit followed fit, until, when a little better, she 
chanced to smell musk, upon which she fell into a 
state of stupor, and was thought to be dying. Then 
the voice fell to a whisper, and so came and went for 
five years, and at last failed so utterly that for the 
last five years she has uttered no sound. Meanwhile 
she stayed in bed till 1872, and had, in succession, 
general paresis, right arm and hand paralyzed, enor- 
mous swelling of hand so as to resemble an abscess, 
and a variety of hyperesthesias ; on one occasion a blow 
on the hand caused retraction of the head, followed 
abruptly by recovery of previously lost power. Soon 
afterwards there were in succession repeated attacks 
of hemiplegia, renewed hysterics, paralysis of left 
leg, and swelling of foot, with exquisite hyperesthe- 
sia of the whole skin. In September, 1872, a slight 
effort brought on palsy of the left arm, so that 
she had finally loss of power in both hands, with 
loss of voice. This was followed by anuria, and then 
by complete absence of saliva, so that for a time the 
mouth was absolutely dry. Meanwhile speechless, 
and with paralysis of all her limbs, she could only 
call any one by seizing the handle of a small bell 
in her teeth and shaking the head. After a year 
and a half the use of induction currents seemed to 
have a good effect, and she was soon able to use her 
hands, and to walk. At this time and for seven years 
the right hand swelled enormously before each men- 
strual flow, and at the close of the week the skin 
came off in large patches. In 1876, she had violent 
retro-spasms of the head and motor ataxia of the legs. 



HYSTERICAL APHONIA. 193 

In 1877, she had hysterical convulsions, photophobia, 
a variety of pains, glossitis, with great swelling of 
the tongue, long attacks of coma, hysterical vomiting, 
and two weeks of nearly complete fasting, and spas- 
modic ptosis. 

You will, I think, agree with me that a more 
miserable catalogue of ills could hardly be made out. 
Within a year the more active troubles have faded 
away, and we have before us only a weak, pale, 
sensitive woman, with complete loss of voice. 

You will remember that this woman was at my last 
clinic, and that I told her she could probably learn to 
speak. Two days later she wrote to me that, for the 
first time in ten years, she had made a sound, and 
this is all, but in the mean while I asked her to come 
to my house, and there I studied her case yet more 
carefully; ai}d now to-day she comes back, and I shall 
test the value of the theory I have formed as to her 
case. But, before I do this, let me say a few words 
as to the types of aphonia and dysphonia connected 
with hysteria. You will find in Cohen's excellent 
book, and in Ziemssen, very good accounts of this 
group of disorders, but I think it will admit of further 
study, and I, therefore, venture here to tell you about 
it -some things which are not found in the text-books. 

Hysterical loss of voice is apt to come on in long 
cases of hysteria without apparent cause. The voice 
goes and comes, is hoarse or feeble, and at last be- 
comes reduced to a whisper, or is lost altogether for 
weeks or years. Then the patient has to write what 
she would have talked ; and if, as in this girl's case, 
her arms be palsied for a time, only manual signs re- 
17 



194 DISEASES OF THE NERVOUS SYSTEM. 

main until the people around her learn to read those 
labial signs with which communication at length be- 
comes so easy as to take away desire to make the 
painful effort at audible speech. 

In a few cases emotion causes abrupt loss of speech 
power. Cohen relates such a case ; I have seen 
several. Nor when we remember that it is through 
the voice-muscles that we express so many of our 
emotions, can we wonder that it is in the larynx that 
we feel the choking spasm of grief, or that here, also, 
intense sense of pathos, or almost any deep feeling, 
asserts its power by some act of muscular spasm ; or 
that in nervous people yet graver emotional shocks 
result in the palsy of the organs through which we 
are prone to express emotion. 

There are, as I have seen them clinically, at least 
three forms of hysteric conditions which disturb vo- 
cal utterance, and these three forms are sometimes all 
seen in one case, or may exist distinct. We have, 
first, bilateral palsy of the adductors of the vocal 
cords; second, disassociation of the various organs 
needed in phonation; third, habitual spasm, or sense 
of spasm, during use of the larynx in speech. 

The first, or bilateral loss or lack of power in the 
crico-arytenoid muscles, is the common type of hys- 
terical aphonia, and is usually found with loss of 
power in some of the other muscles of the larynx. 
If, in a case of hysteria, you have loss of voice, or 
suddenly the patient becomes a whisperer, you may 
be pretty sure that you have to deal with this form 
of trouble. Even if there has been a cold and sore 
throat, with cough, you may safely conclude that the 



HYSTERICAL APHONIA. 195 

slight local inflammation did not cause the aphonia, 
but acted as what I may call a hint to the hysterical 
condition. This caution is, I may add, the more 
needed because an outbreak of this form of trouble 
is often caused by catarrh; but this is the kind of 
thing we see every day in hysteria. The catarrh 
passes into hysteric paresis. A diarrhoea from over- 
eating becomes an hysterical diarrhoea; an attack of 
true emesis from indigestion is the parent of hysteri- 
cal regurgitation, and this may last for years. 

Bilateral hysteric -p&lsy of the vocal cords may be 
extreme or slight, but where it is marked you will 
see, with the laryngoscope, that the cords do not 
come well together when the patient makes vowel 
sounds. One cord may come nearer the middle line 
than the other, but neither does its duty. This is an 
easy examination commonly, because, as a rule, hys- 
terical people are not at all disturbed or gagged by 
the mirror ; but this is not always so, and the patient 
we see to-day has a quite sensitive throat. If you 
find a distinct unilateral glottic palsy, you have, 
probably, a non-hysterical paralysis — at least I have 
never seen a monoplegic state of larynx which was 
hysterical. You would naturally suppose that apho- 
nia and dysphagia would often be found together, 
but this is rare, very rare, although I can recall cases 
where the two disorders alternated. 

The loss of voice in hysteric aphonia has some odd 
peculiarities, or rather exceptions : the patient cannot 
speak, or can only whisper with mouth or larynx so 
faintly as to be scarcely heard with the aid of the ear- 
trumpet ; yet she may be able to sing well, as happened 



196 DISEASES OF THE NERVOUS SYSTEM. 

in one of Cohen's cases ; or, as chanced in that of a lady 
whom we saw together, she may be able to speak aloud 
in her sleep, and then only. On these occasions the 
unwonted sound of her own voice would awaken her, 
and the disappointment which followed the next wak- 
ing effort at speech was most distressing, and the 
emotion thus occasioned gave rise, like all emotion in 
such cases, to an even greater loss of what mere 
whispering power was left. 

Many examples of these disorders are seen in pretty 
strong, stout, and even ruddy women, and when met 
with in such persons are, like all the hysterical phe- 
nomena of the nearly healthy, especially unmanage- 
able. When hysteric aphonia is found in feeble and 
easily-tired women, the effort to speak or cough with 
an open larynx, or with weak chest muscles, gives rise 
to a good deal of soreness, and emphasizes that sense of 
painful fatigue about the pectoral region of which this 
class of invalids is so apt to complain. The victim of 
this disease is very often able to speak low, the voice 
breaking at times. Other and extreme cases lose the 
power to whisper with the larynx, and can still whis- 
per with the mouth ; and others, again, are unable to 
utter the faintest sound, or to laugh or cough so as to 
be heard at all. It must be obvious to you that, in the 
worst cases, we have here a dual condition, a paralysis 
which, though without coarse organic cause, may be 
lasting, and a disassociation of the motor activities of 
the respiratory, laryngeal, and buccal and oral mus- 
cles — parts which, by physiological construction and 
long habit, unite to produce voice. The two troubles 
are often seen together in variable degrees ; or the 



HYSTERICAL APHONIA. 197 

incoordination may exist alone, there being still 
power to close the larynx. 

We should then have the second and less well-known 
form of aphonia, and this it is well to study with care. 
The present case is a perfect example. If, while using 
the throat mirror, I ask her to sound the broad A, the 
vocal cords come together, but do not vibrate, because 
she is unable to use synchronously the respiratory 
muscles to drive air through the narrowed orifice. 
Of course there is no laryngeal whisper. In some of 
these cases, as I have seen, the patient can whistle more 
or less well, because for this act only the mouth and an 
expiratory effort are needed ; but there are others who 
cannot execute even this simple act of coordination, 
and these persons would seem, therefore, to have also 
lost power to use vocally the lesser bellows — the mouth 
— in connection with the tongue and lips, so that in 
this case buccal whispering would also be lost, and the 
patient would then have what Cohen calls apsithuria, 
and be absolutely whisperless. I will defer speaking 
of the third form of dysphonia until we consider the 
case before us. This young woman has good power 
over the laryngeal muscles. I ask her to speak ; she 
makes a great effort, but, as I found in my last ex- 
amination, I cannot hear her even with an ear-trumpet. 
She has neither with larynx nor mouth capacity to 
whisper. She can whistle feebly, but whistling is 
not a feminine accomplishment, or she might do bet- 
ter. You observe that, when trying to speak, she 
makes extreme movements of the lips, and this is 
done to enable her friends to read this language of 
oral signs which she thus renders clear or emphatic. 

17* 



198 DISEASES OF THE NERVOUS SYSTEM. 

What I have here said well enough describes this 
curious condition, which seems not to have been very 
clearly recognized as being sometimes a state apart 
from paralytic conditions. I can give no explana- 
tion of the immediate causes of these singular inco- 
ordinations. Let us now test their presence. It has 
occurred to me that, if I could teach her how once 
more to use with success these disunited activities, 
she might regain her voice. On thinking how I 
could best bring this about, it seemed to me that, if 
I could teach her to speak only with a very full 
chest, I might secure an involuntary success in driv- 
ing air through the larynx. I shall ask her to fill 
her lungs several times, and, when very full, to keep 
her mouth wide open, and, as she sounds or tries to 
sound the broad A, to breathe out violently. I aid 
her by myself performing the act. To her surprise, 
for the first time in ten years, she makes a clear, 
audible sound. Then, always insisting on each single 
letter being made with very full chest, we go over 
the vowels, and then try the labials, and at last words. 
As she leaves me she says, " Thank you." I insist 
that she shall not speak save with a full chest; that she 
must never use oral signs alone ; and that she must 
be silent except during the lessons her sister will now 
give her thrice a day. 

If this had been a case of glottic palsy, I should 
think her sudden cure was due to the emotions caused 
by her novel treatment, as Cohen has seen, and I also, 
the mere use of the throat mirror restore voice; but at 
her first visit here we got no result from this or from 
Oliver's method of manipulating the larynx, so that 



HYSTERICAL APHONIA. 199 

I itself shall believe that the result was due to my 
teaching unused organs the easiest way to regain their 
habitual function. 

Under the use of tonics, rest, and full feeding, with 
vocal lessons, aud a continued order not to speak at 
other times, she has continuously improved. Whe- 
ther or not she will relapse depends a good deal on 
her surroundings. Such cases are only too prone to 
fall back. 

Hysterical spasm of the larynx is a phrase which 
I almost hesitate to use, since I cannot be absolutely 
sure that the disorder I shall describe is really due to 
this cause. There are few of us who, at some time 
of our lives, have not known the sensation of chok- 
ing in the- throat from emotion. It is a brief and 
unpleasant matter, and for well people a rare one, but 
among highly-nervous people, or hysterical women, 
there is a rare form of this trouble, or something 
allied to it, which gives rise to temporary loss or in- 
hibition of voice. At first from emotion, worries, or 
without known cause, there is felt in or about the 
larynx a sense of momentary strangling and pain. If 
the person is speaking, the voice breaks, and she re- 
mains speechless, or the voice becomes shrill and then 
breaks. At every effort there is pain, distress referred 
to the larynx, and squeaky, broken tones. There is 
also a sense of constriction, and sometimes the oesopha- 
gus seems to share in the annoyance, and an upward 
gulping effort follows or accompanies the laryngeal 
disturbance. I have seen this group of symptoms 
become so frequent in one case, that at length the girl 
refused to speak at all. It was apt in this case to fol- 



200 DrSEASES OF THE NERVOUS SYSTEM. 

low meals, and these were seasons of real suffering, 
because of the intense dysphagia, which caused her 
to chew every morsel for many minutes before ven- 
turing upon the task of deglutition. The meal be- 
came, therefore, a severe strain upon an already feeble 
constitution, and this seemed to have something to do 
with the more ready causation of the laryngeal dis- 
order at these special seasons. A long course of milk 
and soup diet, inhalations of nitrite of amyl, and gal- 
vanization of the larynx finally relieved greatly these 
troubles, but there was no entire cure until a year 
later I succeeded in materially improving her gene- 
ral condition. 

We have, then, laryngeal palsies usually with, 
sometimes without, incoordination of the chest, dia- 
phragm, and mouth; pure incoordination without 
paralysis ; and, lastly, a disease which seems to be a 
temporary spasm of the vocal muscles of the larynx, 
caused by effort at speech, in other words, afunctional 
spasm. 



GASTRO-INTESTINAL DISORDERS. 201 



LECTURE III. 

GASTRO-INTESTINAL DISORDERS OF HYSTERIA. 

I have said in these lectures very little as to the 
gravest of hysterical symptoms — the persistent hys- 
tero-epilepsies, and the multiple and severe contrac- 
tions which Charcot and others describe. I have said 
little because, in my experience, and it has been very 
great, these terrible cases are rare in America in any 
class of life, and most uncommon in the lower classes, 
among which Charcot seems to have found his worst 
and most interesting cases. In this disorder, as in 
chorea and many other diseases, there is, I suspect, 
some difference between this country and Europe. 

My own clinic furnishes yearly hundreds of cases 
of neural maladies, but while I often see examples of 
every type of the milder forms of hysteria, it is ex- 
tremely uncommon to encounter the more severe and 
lasting forms of the disease. 

My friend, Dr. C. K. Mills, who has charge of the 
extensive out-wards for incurables at the Philadel- 
phia Hospital, writes me that his experience is simi- 
lar to mine. He says : " My wards contain some 
cases of hysteria of long duration, but they are not 
numerous. As the result of some experience, both 
in and out of hospitals, I have come to the conclusion 

X 1 



202 DISEASES OF THE NERVOUS SYSTEM. 

that cases of grave hysteria, such as the hystero-epi- 
lepsies of Charcot, are rare in this city and country. 
Spasmodic disorders, associated with hysteria, do not 
seem to me to be as frequent here as abroad. Hys- 
terical palsies are more often met with. Neuralgia, 
spinal irritation, ovarian hyperesthesia, and special 
forms of mental and moral perversion are, in my ex- 
perience,, the more usual forms of American hysteria." 
It is impossible to acquire as to a matter like this 
precise statistical information, but from what I know 
of the experience of other physicians in New York, 
Boston, Baltimore, and Chicago, there is every reason 
to believe that it does not differ from the views enter- 
tained by Dr. Mills and myself. The causes of this 
difference in the symptom-products of a disease so 
common, and which finds in all lands and all female 
human nature enough conditions favorable to its 
growth, would be a somewhat interesting inquiry, but 
one for which I must confess there is yet wanting 
satisfactory material. 

I have given in the final lesson of this volume 
some general directions as to the treatment of extreme 
cases of malnutrition and lrysteria. I would like to 
make here some remarks as to the especial difficulties 
which meet us in connection with the stomach and 
bowels of hysterical women. No matter whether we 
treat them, as is preferable, by exercise and baths 
and fresh air and tonics, or are driven in despair to 
the more unnatural treatment by seclusion and rest, 
we have still in all cases, to feed them, and in all to 
see that the bowels are kept reasonably open. The 
lighter cases of hysteria which come afoot to my 



GASTRO-INTESTINAL DISORDERS. 203 

clinic can give yon no idea of the gigantic, almost 
grotesque proportions which symptoms may assume 
in the graver cases of hysteria, but in each and all it 
is nearly always some trick of the stomach or gastro- 
intestinal tract which soon or late baffles or perplexes 
us. In one case you have an apparent inability to 
chew; food rests in the mouth until helplessly removed 
by a nurse or is half passively let fall out by the 
patient. I have such a case now. I had to begin by 
admitting an interest in her failures and advising her 
to move the jaw with the hands, which she did do for 
a while until the power or the belief in the power to 
chew came back. Next comes the oesophagus with 
its troubles — at times a spasm, at times a paralytic 
state, more rarely a pharyngeal anaesthesia — but in 
each case attention to the act of swallowing helps to 
embarrass it. 

You will be well off if you escape this exasper- 
ating disorder in your early hysterical cases. It is 
most enduring, and difficult of relief. I think it curi- 
ous that in my experience this trouble is rare in old 
hysteric cases. There are symptoms which are rela- 
tively common early in cases, others which are seen 
later, and are apt to last. Dysphagia one sees often 
in cases which are afoot. 

If Ave fail of this annoyance, we may have to meet 
certain gastric disorders. One is loss of appetite, 
anorexia ; the other is vomiting. Of this latter symp- 
tom I have already said something in a former lec- 
ture. What I now refer to is the simple regurgitation 
which we meet with in these cases. There is no 
nausea — certainly after a while none, — but the food 



204 DISEASES OF THE NERVOUS SYSTEM. 

is returned to the outer air with a gulp, and often 
with remarkable and painless ease. 

You may think this sounds like a rather mild 
malady ; but in reality it is one of the symptoms 
which, while it may haunt any stage of hysteria, is 
of all symptoms except multiple contractions the most 
enduring. I can now recall five cases of hysteria 
lasting from fifteen to twenty^five years. All are 
bed-ridden ; and while four have contractions, three 
are in the habit of vomiting every meal ; and have 
done this for years. One has actually grown stout 
under this ; but she is an opium-eater, and rest with 
opium greatly aids the storing up of unwholesome 
fat. The others are at least not wasted, and you ask 
yourself in vain how they live upon the small amount 
they seem to retain. In reality there is apt to be 
some deception as to this. Nearly always these 
women assure you that they throw up all of each 
meal ; but they are apt to go through with the matter 
alone or unseen, and no one takes the trouble to learn 
how much is realty retained. I did take this trouble 
once, in a case of which by and by I shall say more, 
and learned that about one-third to one-half of the 
meal remained. In an hysterical girl at absolute rest 
this might very well answer to nourish her amply. 

I put aside for the time the symptom loss of appe- 
tite, because of all of the embarrassments we meet with, 
this is the worst. To call this loss of appetite, ano- 
rexia, but feebly characterizes this sympton. It is 
rather an annihilation of appetite, a lack so complete 
that it seems in some cases impossible ever to eat 
again. Out of it grows an indisposition to eat at all, 



GASTRO-INTESTINAL DISORDERS. 205 

an antagonism to food, which results at last and in its 
worse forms in spasms on the approach of food, and 
thus in turn to some of those remarkable cases of 
survival for long periods without food, which you need 
not confound with the more or less successful efforts 
to deceive by the pretence of fasting. You will have 
constantly to deal with the various grades of this dis- 
order, if you are called upon to treat hysteria. When 
it is merely anorexia, you may disregard it as you 
would the anorexia of fever, no matter how extreme 
it may be, and indeed the more so because it is ex- 
treme. There are some useful hints which you may 
keep in mind for these contingencies. Fluids can be 
taken when solids are inhibited by the disgust they 
cause, but, as regards solids themselves, if they be 
finely divided or put in a fluid as mincemeat in soup or 
rice in milk, they are sometimes taken well whilst if 
alone they would be rejected. I may also add that if 
the patient be in bed you will often be able to give 
solids, if the nurse herself feeds the patient, since then 
you get rid of at least one volitional act, and the 
added chance for deliberation, and consequent disgust 
which it affords. 

Sometimes this symptom exists only at the men- 
strual period, or is then greatly intensified, and, as at 
this time the consequences due to loss of blood are in 
feeble women made worse by failure to eat, one of the 
most valuable lessons you can teach such women is the 
absolute need to eat, or, at least, to drink nutritive food, 
whether it be agreeable or not. The graver cases of 
self- starvation which arise out of the superlative degree 
of hysterical indifference to food are far more serious. 
18 



206 DISEASES OF THE NERVOUS SYSTEM. 

They result, as I have said, in the patient taking no 
food, and sometimes before such cases the utmost 
skill and the largest experience are simply impotent. 
Few of these cases exist without there being a certain 
amount of doubt as to whether or not these long fasts 
are really fasts, yet, as regards some of them, there 
can, I think, be no doubt ; but in no real case has 
the duration of the fast reached that affirmed to have 
existed in examples like that of Louise Lateau. 

I have seen several instances of extreme fasting, 
and I propose now to call your attention to two of 
them which possess a peculiar interest. The first 
one I studied with extreme care and with every 
possible advantage ; the second came to me long- 
after the time of fasting had passed, and although a 
woman to all appearances hopelessly hysterical, com- 
pletely recovered. Her fast was observed by phy- 
sicians as competent as Charcot and Brown-Sequard, 
and of it I have a very good history : — ■ 

Miss L. C, set. now 38 years, had in her 18th year 
an unhappy love affair, and soon afterwards a fall in 
which she struck her back. Within a few weeks 
intense spinal irritation set in, for which braces and 
corsets were used, and, these failing, rest in bed was 
prescribed. The latter remedy was a fatal one, and 
she has never since left the bed to which a physician's 
orders sent her. It were tedious and useless to dwell 
on the wild variety of symptoms which followed, as 
we are dealing now with only one of them. Hys- 
terical paralyses, anaesthesias, ischuria, anuria, poly- 
uria, hjrpersesthesias of skin, eyes, and ears, succeeded 
one another singly or in perplexing groups. A year 



GASTRO-INTESTINAL DISORDERS. 207 

or more before I first saw her, contractions of the two 
legs and feet began, and went on from bad to worse; 
while both legs to the waist were insensible to pain 
and changing temperatures, but still appreciated the 
position of a touch quite fairly well. The body was 
excessively wasted, the skin dry and sallow, and 
covered with bran-like scales of epithelium. About 
the sixth year of her disorder she began to have a 
constipation so obstinate that neither drugs nor 
mechanical aid was of the slightest use, and from this 
time for years the bowels were moved but once a 
month, at which time there were violent attacks of 
hystero-epilepsy. At or near the time when this 
difficulty developed itself fully, she ceased to pass 
water more than once a day. With the help of care- 
ful nurses, I was able to study this curious symptom 
which in her assumed an unusual form. During 
thirty-nine days her urine reached a daily average of 
three ounces. The specific gravity was 1040 to 1060. 
It was dark, and clouded with urates and crystals of 
oxalates and uric acid. The pulse rose to 120; the re- 
spirations to 60 or 70 ; and in place of the usual vomit- 
ing, which Charcot has studied so admirably and which 
he has shown to be vicarious and charged with urea, 
profuse sweats broke out, and left the skin covered 
with a white film in which I found large quantities of 
urea. Then the scene changed, and about the thirty- 
ninth day the sweats ceased, violent vomiting with 
nausea followed, and she began to drink vast quan- 
tities of water, which seemed to be absorbed with 
great speed, since the vomiting which took place at 
intervals was merely of a thick, slimy mucus. At the 



208 DISEASES OF THE NERVOUS SYSTEM. 

same time the anuria ceased, and, from passing some 
days no urine at all, she poured forth large amounts 
of limpid water, sp. gr. 1005 to 1012. 

The fluid thus secreted averaged, for ten days, five 
to ten quarts ; but the amount swallowed was equal 
or more in amount. By degrees this symptom faded 
away, and she drank less and less, and ate almost 
nothing ; until, at the close of another month, the 
urine growing smaller in amount, she ceased to vomit, 
except when urged to take food. Her condition was 
then as follows : She passed six to ten ounces of urine 
daily, and drank, by the teaspoon, about twelve to 
fourteen ounces of water. She took no food at all for 
ten days, and then ate a few teaspoonfuls of milk, 
which always caused vomiting. From this time 
twenty days passed, during which she took no food, 
but had fifty to eighty drops of laudanum daily, Avhich 
she never vomited. Her eyes remained closed, the 
least vibration or light caused agonizing cries, and 
every one expected to see her die at any moment. 
Efforts at rectal feeding or inunction of oils gave rise 
to horrible spasms, and in this condition day after 
day went by. The watch over her was rigid and 
faithful, and every effort even to give a teaspoonful 
of fluid was carefully noted. I am as sure as I can 
be of anything that in one month and five days she 
never took in all more than twenty-four ounces of 
milk, and the amount of water I have mentioned. 
Whether this almost incredible abstinence was aided 
by the large quantity of opium taken is, at least, dif- 
ficult to say. There were, during the time in question, 
a large number of hysterical spasms, but, with this 



GASTR0-1NTESTINAL DISORDERS. 209 

exception, the patient lay almost motionless. Now, 
as yet, we quite lack material for the determination 
of the nutritive needs of a body at absolute rest ; so 
that it is hard to decide how much is needed for the 
mere sustenance of necessary function. I have seen 
a woman, weighing one hundred pounds, remain at 
rest in bed, and lose no weight in ten days on a diet 
of one pint of good milk daily. 

Certainly my patient lost weight. At the close of 
her fast, when she began to take and retain milk in 
small portions, she was wasted almost to the last 
degree, and this has never failed to happen in such 
experiences as I have had of true fasting. This 
woman had in all three periods of abstinence, but the 
one I have described was by far the longest. The 
contractions have of late years become more and more 
extreme, and, as they have increased, the anaesthesia 
has become less, while the electro-muscular excita- 
bilitv of the le^-muscles has lessened. I have little 
doubt that the lateral columns of the cord are now in 
a state of advanced sclerosis. 

The second case of fasting was also one of extreme 
interest, because abstinence was one of a series of 
most interesting phenomena, covering some years ; 
and resulting, finally, in a complete restoration to 
health. 

Miss L., of Connecticut, aet. now 28 years, went 
abroad after having suffered a long and severe strain 
on her emotions and sympathies ; a strain which did 
not lessen, but from which she fled in despair. The 
results were broken sleep, great, though suppressed 
nervousness, but no notable functional disturbances. 

18* 



210 DISEASES OF THE NERVOUS SYSTEM. 

To keep down this sensation of nervous excitement 
she was accustomed to walk for hours, returning home 
with increasing pain and tenderness of the spine, the 
back of the head, and the scalp in general. The symp- 
toms were thought grave, and were at last treated by a 
long blister over the spine. On removal of the blister 
there was a furious outbreak of weeping, general con- 
vulsions, and incessant local spasms of the extremities, 
which nothing checked or lessened. These conditions 
lasted during February and March, and were made 
worse by a large crop of carbuncular boils, which 
formed on the part where the blister had been placed. 
About this time, despite the sagacious care of excellent 
physicians, she began to eat less and less, and at last 
early in April, ceased to eat at all. Exaggerated hic- 
cough set in, furious convulsions arose at every effort 
to feed her, and these symptoms repeated themselves 
six or seven times a day, sometimes without any ap- 
parent cause. Rectal feeding was given up, because it 
also gave rise to spasms, and there seemed nothing to do 
but to wait. For twenty-seven days neither liquid nor 
solid was swallowed. The tongue and lips became black 
and dry, and cracked ; the lips were thin and crusted 
like the teeth with sordes and blood ; the breath 
foul ; the eye sunken ; respiration quick and labored ; 
the pulse 120 to 130 ; and speech whispered and dif- 
ficult. Meanwhile, all convulsive acts ceased, and 
her mind seemed at times quite clear and capable. 
Twice her physicians were called in to see her die; 
but the stupor, which seemed almost as deep as death, 
also, in its turn, passed away. 

I am unable to give details as to the state of the 



GASTRO-INTESTINAL DISORDERS. 211 

secretions during all of this long fast. The bowels 
were, I think, moved once, and the urine ceased to be 
secreted after the eighteenth day. 

There was some difference of sentiment in the con- 
sultation brought about by this grave condition, one 
great authority advising inaction until nature asked 
for food, which he thought would happen. Another 
physician who was then consulted saw in her case an 
example of starvation which, having reached the 
limits of great peril, demanded forced feeding by the 
stomach tube. I am positively informed that of this 
counsel, which it was resolved to follow, the patient 
knew nothing. However, at this critical moment she 
motioned to her physician, and in a whisper said she 
could now take food. Then came two weeks of care- 
ful spoon-feeding, with constant threats of repeating 
the old troubles when, suddenly, a general tremor set 
in, and the motion growing larger, became twitching, 
and so by a crescendo movement went on into violent 
convulsive acts, until despite the care of those about 
her she was thrown by a series of spasms from the 
bed^to the floor, where she lay, muffled with shawls, 
cloaks, and pillows to save her from bruising herself, 
until at length chloroform brought quiet. The sum- 
mer wore away with a variety of symptoms, such as 
partial palsies, aphonia, and mental depression. The 
next autumn she was removed to Liverpool, and there 
during the winter she had variable degrees of ano- 
rexia, and the usual miserable variety of hysterical 
disorders. Treatment was varied enough, but always 
unavailing, because no treatment could ignore food, 
and that was kept at the minimum on which exist- 



212 DISEASES OF THE NERVOUS SYSTEM. 

ence is possible. Early in the next September the 
girl mustered courage to cross the Atlantic, and ar- 
rived in New York, suffering with a loud, incessant 
cough, which brought up strange quantities of glairy 
mucus. Emaciated to the last degree, with evening 
fever and morning chills, she seemed on the verge 
of death, when almost suddenly the cough ceased, and 
the starvation symptoms reappeared, but not in so 
disastrous a shape as had marked their appearance 
in Paris. After a partially successful treatment at 
the hands of her physician in New York, circum- 
stances removed her from his care. Again the sto- 
mach tube was advised and declined by the family, 
and again days passed without food, while the convul- 
sions, the wasting, the black tongue, the breath, 
which Brown-Sequard had described as an odor like 
that of altered fusel oil, and the shrunken belly all pro- 
mised a new period of three weeks' fasting. It proved, 
however, less complete than before, and she gradually 
rallied. From this time she remained in bed for 
nine months, eating little and irregularly, a wretched 
invalid, not very thin, but not fat, with occasional 
spasms, great nervousness, distressed by light, by 
sounds, by any company which was not quite agree- 
able, forever alarming her friends by threatenings of 
a repetition of her former troubles. I somewhat re- 
luctantly took charge of this lady early in the follow- 
ing spring. The most absolute seclusion and the use 
of skimmed-milk diet, aided by massage, slowly 
triumphed over her disorder, and by and by she re- 
gained control over her too emotional tendencies. 
The details of this treatment I have elsewhere dwelt 



GASTRO-INTESTINAL DISORDERS. 213 

upon. It triumphed in this case so completely as to 
have restored my patient to absolute health, and to 
social duties and engagements which, had seemed to 
her hopelessly lost. 

The same obstinacy of symptoms which attends such 
happily rare cases as these is also occasionally met 
with in regard to the function of defecation. 

You will find among hysterical and also among 
merely feeble people several forms of difficulty asso- 
ciated with this function. One which is not uncom- 
mon is a feeling of great weakness after every opera- 
tion. This sometimes goes so far that the patient will 
show clearly enough, in the pallor and the hastened 
heart, how real is the sudden enfeeblement thus pro- 
duced. In still less common cases the patient faints 
after the stool is passed, and is especially apt to do so 
if the evacuation be loose and therefore sudden. I 
know of one man in quite fair health who is never 
without a sense of faintness at and after a passage, 
while a stool at all watery is sure to cause him to faint. 

Naturally enough such phenomena are frequent in 
the class of cases we are uoav considering — so that it 
is sometimes needful to give a little stimulus before 
the evacuation occurs, and also to insist on the use of 
a bed-pan. If you can thus break up a morbid habit, 
or at least make this occurrence of faintness unlikely 
for awhile, the gradual return to full health, which, 
meanwhile, you are in other ways promoting, will 
take care of the future. 

A far more formidable symptom is the indisposition 
of some hysteric women to make any effort towards 
evacuating the bowels. They will tell you that it 



214 DISEASES OF THE NERVOUS SYSTEM. 

gives them intense pain, and that they cannot exert 
themselves, or else they will make, or seem to make, 
efforts which result only in failure. At last you 
begin to find that medicine does not act, and is met 
with resistance. It does this or it does that. It gives 
acute pain, or it disturbs digestion; you try other 
aperients, and always there is some objection, while 
you begin to observe that, for some reason, the 
doses needed are large. If, now, you make a rectal 
examination, you may chance to find the lower bowel 
full of feces, or else absolutely empty, as far as j^our 
powers of local examination enable you to reach. 
Either there is a palsy of the bowel somewhere, or, 
what is practically the same thing, there is a tem- 
porary inhibition of its natural movements. Day 
after day goes by in vain use of enemata and drugs. 
You will recall my mention, in one of these lectures, 
of the case of an hysterical girl thus affected, and also 
what I have said in the present lesson as to the case 
of the patient first described. In her, monthly evacu- 
tion of the bowels has continued, and is now the habit 
of years. I recall another case in which, after pro- 
longed treatment, I advised that the bowels should 
be left to regulate themselves. Three weeks went 
by without an operation, and, when it came, child- 
birth could hardly have been worse. On another 
occasion five weeks elapsed, and then, what is natu- 
rally not rare in such cases, diarrhoea folloAved the 
constipation ; so that for months there was this alter- 
nation — diarrhoea, tenesmus, intense straining, num- 
berless efforts clailv, and then, in a day, all movement 
arrested, and absence of stools for weeks. 



GASTROINTESTINAL DISORDERS. 215 

If it happens to you, in an evil hour, to have one 
of these cases to treat, with the additional need to 
treat also the difficulties with which some tender 
mother surrounds such a case, you are much to be 
pitied. I recall such an example, which I saw in 
consultation some years ago. It begau with a spot 
of abdominal tenderness over the spleen. Pressure 
on this caused nausea and vertigo. Then we had 
convulsions, hysterics, coma, enormous polyuria, and, 
at last, among other things, constipation. The phy- 
sician in charge gave me this list of the drugs given 
in four days — night and morning, on each day, an 
ounce of castor oil ; at mid day and bedtime one drop 
of croton oil ; three drops had been used in one day. 
The more drugs she took the more she demanded, 
and yet it was impossible to see that the doses given 
caused pain. Meanwhile, for the nurse and mother 
the arrangement for each evacuation was the event 
of the day. A long stomach-tube was carried six or 
seven inches up the bowel, and a half pint of olive oil 
injected ; then followed one quart to three of flaxseed 
tea. During the use of the enema one person was oc- 
cupied in compressing the anal opening so as to pre- 
vent the escape of fluid. This help was made neces- 
sary on account of the great relaxation of the sphinc- 
ter, into w r hich a thumb could be passed without any 
resistance which could be felt to arise from a muscu- 
lar act. Meanwhile, the patient, while insisting on 
the use of more water, was shrieking with pain. The 
whole affair took two to four hours, and the patient 
was, I thought, the least exhausted of those concerned. 
Sometimes, their efforts gave rise to a stool; some 



216 DISEASES OF THE NERVOUS SYSTEM. 

times, there was none for a week ; and, sometimes, 
under the wild entreaties of the patient, these trying 
scenes were repeated in the night, nurse and mother 
being aroused to assist. I endeavored to get this girl 
out of the control of her family, but I did not suc- 
ceed ; and I believe that her hysteria is now firmly 
established. 



TREATMENT BY SECLUSION, REST, ETC. 217 



LECTURE XIII. 

THE TREATMENT OF OBSTINATE CASES OF 
NERVOUS EXHAUSTION AND HYSTERIA BY 
SECLUSION, REST, MASSAGE, ELECTRICITY, 
AND FULL FEEDING. 

The lessons I have here gathered together would 
be incomplete, were I not to add some more detailed 
statement of my views as to the general treatment of 
the conditions out of which arise the varied phe- 
nomena of hysteria. Nothing, I think, can be more 
melancholy than an honest survey of the amount of 
good done in hysteria by the host of drugs which go 
to form the so-called therapeutics of this disease. 
In disorders where time is valuable we may find a 
happy resource in the famous class of antispasmodics, 
but as a rule they are swiftly disappearing from the 
apothecary's prescription files, and the physician of 
our day who is called upon to treat hysteria, or general 
nervousness or neurasthenia, wisely contents himself 
with a careful estimate of causes, and an effort to deal 
with these by patient treatment. 

Perhaps no cases are more common in general 
practice, none more annoying, and none more dreaded 
than those of hysteria, in its infinite number of forms 
and its infinite variety of masquerade. The lighter 
troubles, the spasms, rigors, nervousness, and curi- 
ous mental states, which haunt the times of sexual 
19 



218 DISEASES OF THE NERVOUS SYSTEM. 

changes in a woman's life, and especially her pas- 
sage into womanhood, are more or less easily dealt 
with. A careful study of the girl's character, of her 
home surroundings, of the incidents of social life, 
which come with the development of possible passion, 
will be the best guide to treatment, and with the 
obvious indications given us by distinct physical ail- 
ments, local or general, constitute oar chief resources. 

But besides these every-day manifestations of hys- 
teria, we meet in practice with a growing class of 
disorders in which change of social circumstances, 
love affairs, disappointments, and what the French call 
vies manquees, combine with physical accidents to 
create invalids, who unite neurasthenic states with a 
bewildering list of hysterical phenomena. These 
are the " bed cases," the broken-down and exhausted 
women, the pests of many households, who constitute 
the despair of physicians, and who furnish those an- 
noying examples of despotic selfishness, which wreck 
the constitutions of nurses and devoted relatives, and 
in unconscious or half-conscious self-indulgence de- 
stroy the comfort of every one about them. 

These are the cases of chronic hysterical invalidism 
w r hich are so difficult to deal with. There must be 
in every country thousands of these unhappy people. 
They weary doctor after doctor, go hopelessly through 
the various cures, and at last end in therapeutic 
inactivity, or find a refuge in homoeopathy, which 
promises a pill for every symptom, and leaves them 
at last where it found them. 

It is among such cases that we meet with the 
strange and interesting disorders of which I have 



TREATMENT BY SECLUSION, REST, ETC. 219 

narrated so many in these lessons, — disorders which 
are to be met, not by mere symptomatic therapeutics, 
but by a full and clear comprehension of underlying 
causes, and by such treatment of these, whether they 
be moral or physical, as shall destroy the soil in which 
hysteric phenomena flourish. 

You will infer from these few introductory sen- 
tences that I look upon most cases of confirmed hys- 
teria as finally dependent on physical states or defects 
which may first have been directly or indirectly due 
to moral causes, or to these in conjunction with vari- 
ously-produced constitutional conditions. Anaemia 
gives rise to lessened power of self-control, this to 
emotional disturbances, and these, in tarn, to loss 
of appetite, out of which, if the surroundings be 
favorable, come graver nutritive disorder and endless 
invalidism. This is a fair sketch of an every-day 
occurrence. It would be waste of time to dilate on 
matters so familiar. 

In grouping cases of hysteria — and remember 
that I speak now of the old and complicated and 
exasperating forms of this disorder — there is one 
reservation which I shall have to make, and but one. 
It refers to the small group of women in whom Ave 
witness obstinate hysteria associated with a nearly 
perfect state of physical health. As I recall these 
cases they have usually been women in middle life, 
and in easy circumstances. I know to-day of a dozen 
or so of such people who are able to walk about and 
to do much as they please ; women in good condition, 
fat and ruddy, w r ith sound organs and good appetites, 
but ever complaining of pains and aches, and liable 



220 DISEASES OF THE NERVOUS SYSTEM. 

on the least emotional disturbance to exhibit a quaint 
variety of hysterical phenomena. For these women 
there is usually no cure, and you will treat them in 
vain. 

We have, then, the hysterical women who are yet 
well enough to be able to correct the causes of their 
disease by exercise and fresh air ; and in this class we 
find abundantly the cases of hysterical joints, and all 
the range of mild hysteric and mimetic symptoms. 
Once make sure that you have such people to deal 
with, and common-sense hygiene, enforced by a reso- 
lute will, and, when you have their confidence, some 
earnestly given moral advice, will be the most they 
will require. Let us put these aside, and we arrive 
at the classes with an allusion to which I began this 
lesson. They are the old and habitually bed-ridden, or 
couch-loving invalids, who are to-day, as they have 
long been, the despair of the best of us. What shall 
we do with them ? 

For practical purposes we may divide them coarsely 
into two sets — first, the nervous and hysterical woman, 
who is at the same time fat, but, as a rule, anaemic. The 
class is not a large one, nor is its anasmia very pro- 
found. As a rule, there is a look about the fatness 
of these women which is anything but reassuring. 
They are more or less feeble, not large feeders, and 
prone to suffer from excessive tire upon dispropor- 
tionate exertion. I have elsewhere discussed 1 at length 
the probability of there being chemical differences 
between the fat of these and of more healthy people. 

1 Fat and Blood. J. B. Lippincott & Co., 1877. 



TREATMENT BY SECLUSION, REST, ETC. 221 

There is muscle and muscle, fat and fat, and it is now 
become more and more sure that these mysterious 
variations in the quality of tissues, however little we 
may know of their chemistry, are such important fac- 
tors in health that we cannot at all afford to disregard 
them. I say all this, because, when you meet with 
women who are at once very stout, and not too nota- 
bly anemic, you may be disposed to regard them too 
lightly as free from suspicion of any such grave nutri- 
tive disorders as may seem to offer reasonable expla- 
nation of their nervous symptoms. Those who are 
very plainly pallid and flabby, fat and feeble, will, I 
may here say, offer, like the rest of their class, a 
problem not always very easy to solve. We shall, 
by and by, consider how they are to be dealt with. 

There remains, in the second place, the larger class 
of nervous, and exhausted, and hysterical women who 
are, as a rule, weak, pallid, flabby, disfigured by acne 5 
or at least with rough and coarse skins ; poor eaters ; 
digesting ill ; incapable of exercise, and suffering from 
the cold extremities which lack of this, with thin 
blood, occasions. They lie in bed, or on sofas, hope- 
less and helpless, and exhibit every conceivable va- 
riety of hysteria, 

It has been for some years my custom, when in 
these women every other plan has failed, to deal with 
them by a certain combination of therapeutic means 
which has now been securely tested by time and hun- 
dreds of successes. It has stood the criticism and 
won the approval of many competent physicians, who 
have found in it a resource where all else had failed. 

19* 



222 DISEASES OP THE NERVOUS SYSTEM. 

As it is now seven years since I first published 1 a 
formal statement of this method, it seems to me that 
the time has come when I should say in what respect 
my opinions have been altered or confirmed, and what 
changes I would desire to suggest. I shall, therefore, 
give here a condensed statement of the treatment in 
question, and referring to my former publications for 
minute details, shall criticize it in the light of what, 
without want of modest statement, I may venture to 
call an enormous experience. 

The treatment to which in these pages I so many 
times refer, consists in an effort to lift the health of 
patients to a higher plane by the use of seclusion, 
which cuts off excitement and foolish sympathy; by 
rest, so complete as to exclude all causes of tire; by 
massage, which substitutes passive exercise for exer- 
tion ; and hy electrical muscular excitation, which 
acts in a somewhat similar manner to massage, and with 
it by depriving rest in bed of its essential evils, leaves 
only its good. These means enable us to over-feed 
our patients, and to enable them to digest with ease 
large amounts of food. 

I have here put first the idea of seclusion. That 
means separation from indulgent friends and sympa- 
thetic relatives. It is a change in the interest of 
every one concerned, because a chronic invalid is a 
slow poison in a household of loving people. It 
means, too, the breaking up of old habits; and it 
means, usually, a change of diet and personal sur- 

1 Rest in the Treatment of Disease. Seguin series of Lectures. 
Appleton & Co., New York. Fat and Blood, 1877. 



TREATMENT BY SECLUSION, REST, ETC. 223 

rou ridings, because seclusion is not often to be at- 
tained at home. For nervous or hysterical people it 
must be absolute; for merely feeble people, who re- 
tain the power of self-control, and who are to be put 
at rest, it admits of every degree of liberality. We 
should remember, however, that even if a woman be 
only a tired and weak invalid, and not a very nervous 
one, she must, owing to the necessities of the treat- 
ment, see daily the masseuse, the electrician, the 
nurse, and the physician, so that to admit other 
visitors is to make a needless call upon her growing 
strength, which in these cases is sorely taxed by con- 
versation. I do not say that seclusion is impossible 
in the home of the invalid, for I have obtained it with 
success many times, when my nurse was a thoroughly 
good one ; but the other plan of securing it by a 
change of dwelling is better and far easier. Seclusion, 
of course, has for its objects the cutting off of many 
hurtful influences; but, above all, it means the power 
of separating the invalid from some willing slave, a 
mother or a sister, whose serfdom, as usual, degrades 
and destroys the despot, while it ruins the slave. Like 
all rules, this latter one of isolation from habitual per- 
sonal relations, has its exceptions. I have had cases 
nursed successfully by a mother or a sister, but I 
never wish to make the experiment, because it inevi- 
tably makes heavier the doctor's task, and because it 
is nearly always an experiment. Get your patient 
alone with a good nurse, with some woman who is 
trained, intelligent, young, and clever enough to read 
aloud, and with culture enough to make her an agree- 
able companion. Ten years ago there were no such 



224 DISEASES OF THE NERVOUS SYSTEM. 

nurses; to-day there are enough of them; but in 
choosing a nurse, remember that if she has no tact, 
or has a short temper, or is clumsy, or un-neat, you 
may have your case spoiled, or be forced to change 
the nurse midway in your treatment; but, at all 
events, never hesitate about this. If the patient and 
nurse do not agree, make a change, and, if need be, 
another. I cannot enough emphasize this matter of 
the nurse. Put yourself in the place of an intelligent 
lady shut up for two months with a coarse woman, 
whose talk and whose habits disgust, and doubly dis- 
gust, because the victim is emotional and sensitive 
by nature and by habit, and you will realize the need 
for care in your choice of an attendant. Mere technical 
training will not answer, and I have seen an utterly 
untrained woman, of good brains and tact, win suc- 
cesses which are sometimes denied to the best edu- 
cated nurses who lacked those ever-needed moral 
qualities which no training and no length of expe- 
rience will give to some women. 

And now, having your patient isolated and the 
nurse in charge, certain grave questions arise. We 
will presume that the case has been found to be suit- 
able, and that the patient has come within your own 
control — whether at her home or elsewhere — that her 
case is new to you, and that you have decided to use 
rest. The first question you will have to settle is as 
to whether it be wise when using this treatment to 
correct all womb troubles at once, or to wait, or to 
neglect them altogether ? I am guided as to these 
matters by the following rules : In the case of mar- 
ried women, I make or cause to be made a thorough 



TREATMENT BY SECLUSTON, REST, ETC. 225 

examination to begin with. If there be only conges- 
tive states and their consequences, I trust to the 
general treatment for cure. If there be marked dis- 
placements or excessive menstruation I like to correct 
the one and have the uterus well searched for possible 
causes of the other. Should there be grave fissures 
of the neck of the womb or perineal rupture I prefer 
to have these relieved at once if the patient be in a 
moderately good state, but if the case be one of ex- 
treme feebleness I prefer to delay all surgical inter- 
vention until the improved conditions which follow 
my treatment offer a better chance of successful 
mechanical interference. If the patient be a virgin, 
and there seems little reason to suspect misplace- 
ments, I trust again to the general treatment. If, 
moreover, there be plain evidence of misplacement, 
and the patient be of that temperament which makes 
vaginal examinations disastrous shocks to the nervous 
system, I wait patiently the result of the rest and its 
aids. Then at the close of two months I like to make 
an effort at local relief, in the hope that with a rein- 
forced nutritive life my patient may bear the strain. 
Dr. Goodell will remember cases, seen with me, in 
which the patient, having retroversion, decided to 
undergo no mechanical treatment, and has seemingly 
become and remained well, under rest, etc., despite 
the uterine trouble. 

Misplaced ovaries cause in my experience a great 
deal of trouble, but both Prof. Goodell and I have seen 
a number of cases in which this annoying complica- 
tion righted itself spontaneously during treatment by 
rest. In one of these cases, the misplacement was so 



226 DISEASES OF THE NERVOUS SYSTEM. 

extreme and the symptoms caused by it so grave that 
the propriety of double ovariotomy was more than 
once discussed. We were pleasurably surprised as the 
treatment progressed to find a gradual slipping up- 
wards of the ovaries until at last they regained their 
usual place. This change accompanied a remarkable 
gain in vigor and in flesh. I have never yet been 
able to make clear to myself precisely why under 
these circumstances the ovaries should be drawn up, 
but Prof. Goodell's opinion in a matter of this kind 
must be far better than mine, and as he thinks there 
is a competent physical explanation, I give his re- 
marks in full : " The ovaries should be daily re- 
placed by atmospheric pressure, the knee-breast pos- 
ture, and the result is that they finally go up to stay 
up. Under the influence of the general gain in 
health, and the local handling of the masseuse, the 
organs cease to be congested. Then the increased 
deposit of fat in the abdominal walls, in the omental 
apron, and around the viscera, to say nothing of the 
needful fat-padding in all the pelvic nooks and cran- 
nies, increases the retentive power of the abdomen." 1 

" By its gravity the now fat-laden and overhang- 
ing wall of the abdomen tends to draw toward itself, 
that is to say upward, the movable AYall of the pelvis. 
The behavior is like that of a half- filled India-rubber 
ball, in which bulging at one portion causes a corre- 
sponding cupping at another." 

You are now ready to put your patient at rest in 
bed, and you will not, I trust, despise any details which 

1 Lesons on Gynaecology, Groodell, p. 116. 



TREATMENT BY SECLUSION, REST, ETC. 227 

will make rest endurable and useful. You cannot 
always get, but you can desire to get, sunshine, an 
open fireplace, a well-made bed, and a lounge for 
change. 

Rest means with me a good deal more than merely 
saying " Go to bed and stay there." It means care 
that letters bring no worrying news, that they are 
brief and of such kind as a nurse may read aloud. It 
means absence of all possible nse of brain and body. 
It means neither reading nor writing;, at least for a 
time, with exceptions in cases where, as is rare, there 
is no asthenopia. If the nurse can read to the patient, 
and reading be borne without fatigue, let it be used at 
first for only a few minutes at a time. If this wearies, 
then let the nurse try to cull the bits of interesting 
news from the papers, and as she glances over the 
columns talk this to the patient in place of formally 
reading aloud. Why this tires less than reading I do 
not know, but that it does so I am sure. If you are 
disposed to smile because I say let the nurse feed the 
patient, you will not, if, lying supine, you make the 
experiment of using your own hands in this act of 
feeding. Or even if seated in bed you do this, you 
will find that the effort is singularly tiresome. I be- 
lieve I have done something to make rest fashion- 
able among physicians as an essential in the treat- 
ment of spinal maladies, and both in them and in 
the treatment of neurasthenia and hysteria it is well 
that you clearly comprehend what it is that I mean 
by rest. Your trouble will be always that the pa- 
tient will desire to lie on a sofa, or to make some 
such compromise, but in bad cases, and it is only of 



228 DISEASES OF THE NERVOUS SYSTEM. 

these I speak, all this is but mere trifling, and you had 
better, on the whole, make an error in the direction 
of a too absolute rest. 

The moral uses of enforced rest are readily esti- 
mated. From a restless life of irregular hours, from 
hurtful sympathy and over-zealous care, the patient 
passes into an atmosphere of quiet, of orderly control, 
and under the care of a thorough nurse. The result 
is always at first, whatever it may be afterwards, a 
sense of relief, and a remarkable and often a quite 
abrupt disappearance of many of the nervous symp- 
toms which had previously harassed the patient. 
With this first sense of ease comes the precious chance 
of the doctor for moral medication. He can now point 
out that, however hard it was with failing powers to 
control emotion and suppress nervousness, it is easy 
to do all this when the physical condition is improv- 
ing. This doctrine will be aided and enforced by the 
nurse if a good one, and your patient will be con- 
stantly reminded that she is getting better physically, 
and is expected to accomplish more and more in the 
way of self-restraint. If she fails you praise the 
effort. If she succeeds you applaud the success. You 
are her whole audience, and this with an hysterical girl 
gives you great power. Why rest is of therapeutic 
value I have elsewhere more fully shown. It is of 
more use here to urge that, like all medication, it has 
its evil side, and that it is to the other parts of this 
system we must look for the means of overcoming and 
counteracting them. Ordinarily prolonged rest en- 
feebles circulation, weakens digestion, lessens appetite, 
and constipates the bowels. The active muscles are 



TREATMENT BY SECLUSION, REST, ETC. 229 

every one of them pumps, which subject the local 
blood circuits to sudden flushing, and the heart in a 
person at rest loses twenty beats a minute, and thus 
adds to the passive mischief. Moreover, the liver and 
the double abdominal circulation, and the moving 
bowels cease to have the constant stimulation which 
they get when we are afoot, and so in many ways 
damage is done. Rest, then, is, or may be, hurtful. 
We turn to massage and electricity for aid in correct- 
ing this. Massage, or kneading of the muscles, has 
been long used in Europe and the East. It is the 
"shampooing" of the oriental, the "lammi lammi" of 
the Sandwich Islander. I do not know that it has been 
used except by me as a systematic daily mechanical 
tonic. For details of just how it ought to be done, 
and with what caution, and how long and what are 
the immediate physiological effects, I must again refer 
to my book, on Fat and Blood. Used daily, half an 
hour to an hour, it is a pleasant and refreshing process, 
and even when, as does happen, it seems at first to 
tire, all of this result, soon or late, passes away. 

It substitutes exercise for exertion, and does nearly 
all that a moderate amount of active muscular motion 
can do in the way of warming the limbs, increasing 
the blood-flow, stimulating the local circulations, and 
reddening the skin. It may, and should, at last, be a 
pretty violent influence, and, by and by, may be used 
in such a way as to jog the intestines like the invalu- 
able shaking given by a rough trotting horse. To be 
thoroughly done it needs a trained masseuse, but any 
clever person, who is strong enough, may easily 
learn to do it; and it enables one daily to rub into 
20 



230 DISEASES OF THE NERVOUS SYSTEM. 

the skin a large amount of some nourishing oil, like 
that of the olive or the cocoanut. I never could see 
why a tonic so valuable as this should be left to assist 
the triumphs of the charlatan ; and I feel that, in 
making it of easy use, I have clone that which, in 
many ways, is valuable to the surgeon and the phy- 
sician. You will meet with some difficulty in having 
the back kneaded when there is spinal irritation, but 
as to this you must be relentless ; and the masseuse, 
by degrees approaching the sore spots, will in time 
come to treat them as thoroughly as any other part, 
and with the sure result of, by and by, lessening and 
destroying the local sensitiveness. In like manner 
the hyperesthesias of other regions may be dealt 
with, and, above all, that which is sometimes a truly 
ovarian, and sometimes merely an abdominal surface 
sensitiveness, may, with time and cautious patience, 
be relieved or cured. 

Massage is, in these cases, absolutely essential : elec- 
tricity is very desirable ; but we can, in many cases, 
do without it. 

It involves the daily use of induction currents (slow 
interruptions) to almost every muscle which can be 
reached ; the object being to throw each muscle into 
decided contraction. Finally, a mild current with 
rapid breaks of current is made to pass from the neck 
to the feet for fifteen minutes. That it is, thus used, 
a powerful tonic I have not the faintest doubt, and I 
commonly use it with massage, except where the need 
to save expense is of moment. 

These means are employed to prevent rest from 
being hurtful, and to enable us to fatten and redden 



TREATMENT BY SECLUSION, REST, ETC. 231 

the patient by a methodical system of over-feeding, 
with the use of proper tonics. I have already said that 
there is some trouble in treating fat and anaemic wo- 
men. You may cure them by ordinary means, but it is 
easiest and safest to do so by putting them at rest, and 
under-feeding with milk, so as, at first, materially to 
reduce the flesh, after which the patient may be sub- 
jected to the usual treatment by massage and the 
other means I have detailed. It is easy, with perfect 
security, to lessen the fat rapidly, if only the patient 
be kept in bed ; otherwise, as we have too well known, 
it is a dangerous and difficult thing to effect. I may 
add that if there is much, or a very obstinate dyspep- 
sia, it is well to begin the treatment of any case by 
Card's milk treatment. It is astonishing how this 
simplifies matters, and how under milk, massage, and 
rest the whole train of nervous ills melts away in a 
few days ; and how we are able to dispense with 
chloral and morphia, or habitual use of other drugs. 
Indeed I may add that I should be sorry, now-a-daj^s, 
to treat any old case of the opium habit without these 
invaluable aids. 1 

In fact, if I have the least doubt, I never fail to 
begin in any case of treatment by rest, with milk as 
the sole diet ; while, of course, there are also many 
cases where it is used only as an adjuvant, and I 
simply feed the patient in the ordinary manner. By 
some such plan the patient has the diet gradually 
increased, until it is common to see her take three 
meals as well as two quarts of milk, six to nine ounces 

1 Am. Jour. Med. Sci., Oct. 1866. 



232 DISEASES OF THE NERVOUS SYSTEM. 

of Hoff's fluid malt, and a variable amount of raw 
soup between meals and at bedtime. 

Iron in large doses, alcohol rarely, and cod-liver oil, 
by the mouth or rectum, when well borne, are to be 
added as indicated. 

The result of two months of such treatment, in 
pale, bloodless, meagre, and nervous women, must be 
seen to be believed or duly appreciated. You have 
seen it here often enough to fully understand me. 
Each and all of the means described are to be slowly 
and by degrees laid aside, and then you have as care- 
fully to get your patient up and afoot. Of late I 
have been in the habit of preparing for this by allow- 
ing the nurse or masseuse to exercise the patient, 
while in bed, with a series of slowly- executed Swed- 
ish gymnastics, which are continued in a modified 
form, when the patient gets up. If this be well and 
pleasantly managed, it is both agreeable to the patient 
and a valuable means of training the muscles. 

The final results of all this treatment when it suc- 
ceeds are to reasonably increase the bulk of the body, 
to improve the moral and physical tone, and to cure 
the anasmia. These changes are obvious in some de- 
gree early in the case, the flesh shows first in the face, 
and the gain in blood in the pink of the finger-nail, 
which I am apt to watch and note. I have been many 
times asked if these amendments or cures are per- 
manent, and I believe I am now, after a careful re- 
view of some hundreds of cases, fully able to say that 
they are quite as lasting as the cures of any nutritive 
defects obtained in more ordinary ways. It is a plan 
never to be used where exercise, outdoor life, tonics, 



TREATMENT BY SECLUSION, REST, ETC. 233 

or change have not been thoroughly tested ; but where 
these have failed it leaves us with a novel resource 
without which no case of broken constitution, nerv- 
ousness, or old hysteria should be left to hopeless 
invalidism, and to a life in bed, or on a lounge. I 
never use it if I can do without it ; but in well-chosen 
cases I use it, with a confidence which has become 
alike courageous and habitual. 



20* 



INDEX 



ABDOMEN, chronic spasm of 
walls of, 115 
Abdominal muscles, spasm of, 

101, 115 
Alternatinghysterical spasms, 37 
Analgesia, transfer of, in hemi- 
plegia, 24 
Ankle clonus in hysteric hemi- 
plegia, 23 
Anorexia, hysterical, 205 
Anstie on mimicry of disease, 59 
Aphonia, Cohen on, 193 

from incoordination, 196 
hysterical, 191 
forms of, 194 
treatment of, 198 
Apsithuria, 197 
Ashe on chorea in negro, 142 
Athetosis, hysterical, 102 

simulated, 102 
Atropia in chronic spasms, 117 
Aura in sensory shock, 154 

BEMISS on chorea in negro, 
143 
Briquet and Lasegue on hysteri- 
cal motor ataxia, 34, 37 
on hysteric hemiplegia, 22 
Buzzard on hysterical hemi- 
plegia, 23 



CABELL on chorea in negro, 
142 
Calf, chronic spasms of, 11 5 
Card's milk cure, 231 
Cases — 

alternating spasms, 37 



Cases — 

cerehro-spinal meningitis, 

simulated, 68 
double hemiplegia, 25, 30 
habit chorea, 148, 149 
hysterical anorexia, 206, 
209 
aphonia, 191 
hemiplegia, 23 
motor ataxia, 38 

with hemiplegia, 43 
paralysis, 13 
paraplegia, 16 
paresis, 46 
spasms, 91, 99 
imagined disease, 61 
imitated epilepsy, 64 
mimicked disease, 69, 71, 

72, 73 
neuralgia from imagination, 

59 
nocturnal hemiplegia, 171, 

172 
ptosis, spasmodic, 124 
sensory shock, 153, 158, 
160, 161, 162, 163, 164, 
167, 169 
simulated athetosis, 102, 104 
disease, 65, 75, 80, 82, 
84 
spasms, chronic, 118 

simulated, 120 
on rising, 96 
tremor, alcoholic, 113 
hysteric, 107 
localized, 111 
neryous, 110 
Charcot on hysterical hemi- 
plegia. 23 



236 



INDEX 



140 

Chorea, deaths from, in Phila- 
delphia, 141 
Ellis on, 140 
explanation of tables of, 130, 

131 
Finley on, 138, 142 
Gerhard on, 128, 129 
Hirsch on, 138 
in cities, 139 
in country, 139 
in Lisbon, 139 
in negro, 142 

Ashe on, 142 

Beniiss on, 143 

Cabell on, 142 

Edwards on, 144 

Geddings on, 143 

Kollock on, 142 

Lee on, 142 

Michel on, 143 

Porch er on, 143 
in southern latitudes, 139 
Landetta and Decastro on, 

138, 142 
Lewis on, 129 
occurrence of, 136 
of childhood, 127 
relation of, to barometer, 
213 

to climate, 138 

to mean relative hu- 
midity, 132 

to mental labor, 135 

to moisture with cold, 
132 

to race, 141 

to rain-fall, 133 

to season, 128 

to storms, 134 

to temperature, 132 
Rufz on, 138 

season of maximum of at- 
tacks of, 132 
See on recurrence of, 136 
varieties of, 145 
Von Ziemssen on, 138 
Cohen on aphonia, 193 



| Color sense in hysteric hemi- 
plegia, 23 
Crutches for motor ataxia, 42, 43 



DEFECATION in hysteria, 213 
Disturbance of sensation in 
hysteric hemiplegia, 22 
Double hemiplegia, hysterical, 25 
Duchenne on hystero-palsies, 32 
Dysphagia, hysterical, 202 



EDWARDS on chorea in negro, 
144 
Electricity, faradic, 230 
Electric reactions in hystero- 
palsies, 32 
Ellis on chorea, 140 
Exhaustion, nervous, treatment 
of, 217 



FAT, excessive, treatment of, 
231 
Finley on chorea, 138, 142 
Flushing, unilateral, in hysteria, 

184 
Forms of crutches for motor 
ataxia, 42, 43 

GASTROCNEMIUS, spasm of, 
101, 102, 115 
Geddings on chorea in negro, 143 
Gerhard on chorea, 128, 129, 137 
Goodell on displaced ovaries, 

225, 226 
Gymnastics, Swedish, 232 

HABIT chorea, 146 
symptoms of, 147 
treatment of, 149 
Hammond, Dr. Wm. A., 102 
Hemiplegia, hysterical, 20 
ankle clonus in, 23 
Briquet on, 22 
Buzzard on, 23 
Charcot on, 23 



INDEX 



237 



Hemiplegin, hysterical — 
color sense in, 23 
disturbance of sensation 

in, 22 
ovarian tenderness, 23 
patellar reflex in, 23 
peculiarities of, 22 
nocturnal, 171 
Hirscli on chorea, 138 
Hysteria, defecation in, 213 
forms of, 219 
gastro-intestinal disorders 

of, 201 
irregularities of pulse in, 178 
Mills on, 201 
paralyses of, 13 
paresis of vessels in, 184 
pulse in, 175, 178 
respiration in, 188, 189 
treatment of, 217 
vasal disorders in, 181, 184, 

185, 186 
with defective nutrition, 48 
Hysterical spasms, 91 

alternating, 37 
Hys tero-epilepsies, rarity of, in 

America, 201 
Hvstero-palsies, sudden cures 
of, 29 



"IMAGINED diseases, 61 
1 Imitated paresis, 59 
Ischremia, cutaneous, 182 

in hysterical paralysis, 
181 



K 



EEN, Dr. W. W., 102 

Kollock on chorea, 142 



IACK of coordination in hys- 
J terical motor ataxia, 35, 36 
Landetta and Decastro on chorea, 

138, 142 
Larynx, hysterical spasm of, 199 
Lee on chorea in negro, 142 
Levis, nerve section, 183 



Lewis on chorea, 129, 137 
Lisbon, chorea in, 139 



MALARIA, relation of, to 
chorea, 140 
Massage, uses of, 229, 230 
"Metal cure" in hysterical 

hemiplegia, 24 
Michel on chorea in negro, 143 
Milk, treatment by, 231 
Mills on hysteria, 201 
Mimicked disease at Church 

Home, epidemic of, 69 
Mimicked disease, causes of, 51 
automatic imitation, 57 
general nervousness, 52 
hysteria, 53 
lowered health, 53 
mental influence, 54 
nervous temperament, 

52 
physical peculiarities, 

53 
sympathy, 57 
Mimicry of disease, 50, 75 
Morehouse, Dr. George R., 102 
Motor ataxia, hysterical, 34, 38 

two forms of, 34 
Mustard- plaster in hysterical 
hemiplegia, 24 



NEGRO, chorea in, 142 
Nervousness, general, 52 
Niedit-teiTors, 166 



OVARIES, displacement of, 
225, 226 
tenderness in region of, in 
paraplegia, 18 



PAGET on mimicry of disease, 
50 
Paralyses of hysteria, 13 
Paralysis, infantile, relation to 
temperature of, 136 
Sinkler on, 136 



238 



INDEX. 



Paraplegia, hysterical, 16 
Paresis, hysterical, 45 

of vessels in hysteria, 1 84 
Pectoralis major, spasm of, 100 
Philadelphia, deaths from 

chorea in, 141 
Porcher on chorea in negro, 143 
Ptosis, spasmodic, 123 
Pulse in hysteria, 175, 178 

RAGE, relations of, to chorea, 
141 
Respiration, failure of, in sleep, 
172 
in hysteria, 188, 189 
rapid, 190 

treatment of failure of, 173 
Respiratory disorders, 174 
Rest, treatment hy, 227 
Reynolds on mimicry of disease, 

50, 59 
Rhigolene freezing in hysterical 

hemiplegia, 24 
Rufz on chorea, 138 

S CHAFFER on mimicry of dis- 
ease, 50 
Seclusion in hysteria, 222 
See on chorea, 136 
Sensation in middle line in 

double hemiplegia, 28 
Shock, auditory, 157 
olfactory, 157 

sensory, clinical relations 
of, 166 
treatment of, 168 
visual, 157 
Simulated disease, patients' de- 
scriptions of, 82, 85, 87 
treatment of, 78, 81 
Skey on mimicry of disease, 50 
Sleep, disorders of, 153 
Spasmodic affections, unusual 

forms of, 90 
Spasms, chronic, 114 

atropia in, 117 
duration of, 116 
from nerve injuries, 114 
mimicked, 122 



Spasms, chronic — 

of abdomen, 115 
of calf of leg, 115 
of hysteria, 115 
of leg and thigh, 116 
power of, 117 
simulated, 120 
traumatic, 121 
treatment of, 1 19 
functional, resemble chorea, 

98 
hysterical, 91 

alternating, 37 
local (see Tumors, phan- 
tom), 
rotatory, 92 
Strychnia, necessity for rest 
when using, 94 



TENDERNESS, ovarian, in 
paraplegia, 18 
Tendon reflex, patellar, in hys- 
teric hemiplegia, 23 
Treatment of double hemiplegia, 
29 
of hysteria with defective 
nutrition, 48 
Tremor, alcoholic, 113 
forms of, 106 
hysteric, 106 
_ nervous (see Nervousness, 
general), 52 
organic, forms of, 109 
Tumors, phantom, of abdomen, 

101, 115 

of gastrocnemius, 101, 

102, 115 

of great pectoral muscle, 
100 



UTERUS, treatment of, in hys- 
teria, 225 

VASO-MOTOR disorders, 174 
cold feet in, 181 
of skin in hysteria, 184 
Vomiting, hysterical, 203 
Von Ziemssen on chorea, 138 



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